When should someone with CKD see a dietitian?

by KNI

Table of Contents
    Ig 5 Triggers Refer Dietitian Nephrology Kni Jun22
    “5 Clinical Triggers to Refer for Nutrition Therapy with a Renal Dietitian”

    An individual plan is better than a “renal diet”

    There are many benefits to visiting with a renal dietitian for those diagnosed with kidney disease.  First and foremost – quality of life.  Any chronic disease diagnosis is scary.  Kidney disease is no exception.  With the diagnosis of chronic kidney disease, people often feel overwhelmed – with a lot of that overwhelm coming from “What do I eat now?”  The internet is a black hole of information, almost worthless for many patients because the renal diet information presented there is BROAD and not specific to the stage of kidney disease.  In addition, every single person with renal disease needs different guidelines and has different questions. There is no one handout or diet or menu plan that fits every patient. The best service a nephrologist or primary care doctor can provide for his/her  patient is to add a renal dietitian to the care team.

    Nutrition therapy(with a dietitian) for kidney disease makes a difference!

    Research shows that nutrition therapy for kidney disease improves lab work, helps people maintain kidney function longer/delay dialysis, and decreases patient stress and confusion.  In fact, some studies show that diet therapy can be MORE EFFECTIVE than adding a maximal dose ARB (Angiotensin Receptor Blocker) blood pressure medications(1). Even for people who had nutrition therapy intervention but still eventually needed dialysis, there were lasting benefits to the time spent learning and changing their diet prior to dialysis. For example, some studies showed decreased mortality during the first year on dialysis therapy IF the patient received nutrition therapy prior to starting dialysis (2).

    Why aren’t patients immediately referred to renal dietitians?

    The truth is, the referral rate stinks for people with kidney disease.  Often a person visits their nephrologist and is never connected with a dietitian.  Some studies show as many as 88% of patients are not referred to a dietitian (not good!) (2). Even more importantly, surveys have shown that more than 80% of newly diagnosed patients WANT nutrition information (3).  This disconnect isn’t always the fault of the doctor.  Sometimes they just don’t know where or when to refer their patients for nutrition therapy.  Good news for doctors and patients: the National Kidney Foundation is putting together a database of renal dietitians able to provide nutrition therapy!

    Some doctors do their own nutrition counseling or have the nursing staff complete this vital step. Personally, I think this can be a disservice to patients. A big behavior change (like diet) isn’t just about a “do” and “don’t” list of foods. It is about accommodating food preferences, targeting easy changes, talking through a plan for more difficult changes, and knowing what the main nutrition priorities are to focus on. Patients may make changes out of fear, but the best changes come from empowerment and really understanding how food is impacting kidney function.  THAT is the specialty of renal dietitians. And, yes, I am biased, but I believe the best nutrition care for renal disease comes from a renal dietitian or a dietitian with extensive experience in this area.

    When should someone with CKD see a dietitian?

    There are at LEAST FIVE big events that warrant a visit with a dietitian.

    1. A new diagnosis of kidney disease. If a person leaves a nephrologist or primary care physician office with a new diagnosis of chronic disease they should also be leaving with the name of a dietitian. Period. I really see any exceptions to this. Otherwise the internet starts becoming the source, not the professional. And we all know how confusing internet searches can be.
    2. A decline in kidney function. If someone goes from Stage 2 to now Stage 3 kidney failure or Stage 3 to 4 – especially with significant proteinuria or other associated conditions like high blood pressure, they should see a dietitian.  Again, I don’t really understand why a practitioner would not encourage this. (P.S. I don’t buy the excuse “it won’t make a difference anyways.” Even small changes can make a big difference.)
    3.  High potassium or high phosphorus levels.  Sometimes a patient can look at a handout of “High Potassium Foods” and know exactly what bumped their potassium level up. But not always.  I had a client once who was perfectly following every list he had been given by his doctor and had super high potassium levels.  The culprit? He had switched out his milk for non-dairy creamer and was drinking 2-3+ cups/day.  It took some real digging to find this out because the brand of non-dairy creamer did not list potassium content.  We had to contact the company to figure out the potassium content.  To make matters worse, potassium is confusing on labeled products.  The labels are often not accurate or don’t list potassium at all.  I’ve seen lots of products that list potassium as “0 mg” when in fact there is loads of potassium in the product. Talk about confusing for someone who is already trying to navigate several other pieces of their label! Like I said, more on THAT issue coming up.  Finally, there then comes all the recommendations for a “plant based diet.” But, um, aren’t beans high in potassium? And lots of fruits and vegetables? How does that fit in???  (It does by the way.  And is highly recommended. But it is sooo confusing to figure out just from the internet)
    4. High blood pressure.  The research is stunning on the difference that diet therapy can make for blood pressure. And you know what? It isn’t just about salt. Cutting sodium is an enormous part of the picture. But, fruit and vegetable intake are an inescapable piece of blood pressure control as well. And this is where it can get dicey for people.  They get confused about produce and what is really “allowed” for kidney disease.   Far too often, people with early stage kidney disease (stage 3) are unnecessarily cutting high potassium produce (per the recommendations of the internet) and thus potentially impacting their blood pressure, which is already a challenge to control.  And you know what? If you still have a good amount of kidney function, you don’t need to cut potassium.  So yeah, working with a dietitian, could make a big difference in sorting out the produce question and identifying where all that salt is coming from in your diet.
    5. When a patient has questions! When a patient comes to visit with me, my first question is “What is your biggest concern?” Everyone has one when it comes to their food and THAT is what we talk about first, but there is rarely only one concern.  Physician offices are busy places.  Often there is not time to answer all the many questions that can come with the renal diet.  But guess what? A dietitian has time and insurance will often pay for the visit. Medicare covers at least 3 hours of nutrition therapy for the first year after a referral and 2 more hours for every year after that.  Private insurance will also often cover nutrition therapy if the dietitian is within their network.

    A handy resource to remember referrals

    I created this handy, simple flier to post in a nephrologist office as a reminder of when referrals  for nutrition therapy should happen.  For dietitians reading this, please use!  It is uploaded to the Renal Education Library in the Freebie section.   For people with kidney disease reading this, please ask your doctor about visiting with a renal dietitian.  They really can be your best cheerleader and help you make the renal diet #livablelovable and not confusing!  There are so many good foods to eat, even with dietary restrictions that may be needed!

    References:

    1. Slagman M C JWaanders FHemmelder MH,  et al. Moderate dietary sodium restriction added to angiotensin converting enzyme inhibition compared with dual blockade in lowering proteinuria and blood pressure: randomised controlled trial 
    2. Slinin, Y, et al. “Prehemodialysis Care by Dietitians and First-Year Mortality After Initiation of Hemodialysis.” American Journal of Kidney Disease, Elsevier, 29 June 2011, www.sciencedirect.com/science/article/pii/S027263861100850X.
    3. Hollingdale, Rachel, et al. “FACILITATING DIETARY CHANGE IN RENAL DISEASE: INVESTIGATING PATIENTS’ PERSPECTIVES.” Journal of Renal Care, Wiley/Blackwell (10.1111), 6 Aug. 2008, onlinelibrary.wiley.com/doi/abs/10.1111/j.1755-6686.2008.00034.x.

    5 thoughts on “When should someone with CKD see a dietitian?”

    1. Zalina mohammed ralph

      Thank you for you information it’s very helpfull .i appreciate all the help renal patient could get ecpecially as i have lost a love one from renal disease .i am hypersensitive and diabetic so i will follow you thank you

    2. I have CKD IV. My Nephrologist has not referred me to a dietician yet! He just tells me to cut out salt. How can you help me?

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