This is the current release of the guideline.

This guideline updates a previous version: American Dietetic Association. Chronic kidney disease (non-dialysis) medical nutrition therapy protocol. Chicago (IL): American Dietetic Association; 2002 May. Various p.

Overall Objective

To provide medical nutrition therapy (MNT) guidelines for chronic kidney disease (CKD) to prevent and treat protein-energy malnutrition, mineral and electrolyte disorders, and to minimize the impact of other comorbidities on the progression of kidney disease, e.g., diabetes, obesity, hypertension and disorders of lipid metabolism

Specific Objectives

• To define evidence-based CKD nutrition recommendations for registered dietitians (RDs) that are carried out in collaboration with other healthcare providers
• To guide practice decisions that integrate medical, nutritional and behavioral strategies
• To reduce variations in practice among RDs
• To provide the RD with data to make recommendations to adjust medical nutrition therapy (MNT) or recommend other therapies to achieve desired outcomes
• To develop guidelines for interventions that have measurable clinical outcomes
• To define the highest quality of care within cost constraints of the current healthcare environment

Adults diagnosed with chronic kidney disease

Evaluation

1. Referral to a registered dietitian
2. Nutrition assessment
   • Client history including medical, social, and personal history and history of medications and supplements
   • Biochemical data and relevant laboratory values
   • Anthropometric measurements including height, weight, body mass index (BMI), waist circumference, and weight change rate
   • Nutrition history including food intake, physical activity and exercise, food availability, psychosocial and economic issues impacting nutrition therapy, and consideration of co-morbid conditions
   • Physical examination findings

Management/Treatment

1. Individualized prescription based on:
   • Nutrition intervention such as intake of protein, energy, phosphorus, sodium, calcium and vitamin D and multivitamin supplements, fish oil/omega-3 fatty acids, iron supplementation
   • Physical activity interventions
   • Behavioral interventions
   • Management of co-morbidities such as anemia, hyperglycemia, dyslipidemia, and hypertension
2. Coordination of nutrition care
3. Monitoring of progress

General Methods for Collecting/Selecting the Evidence

The following list provides an overview of the steps which the American Dietetic Association (ADA) evidence analysis team goes through to identify research through database searches.

1. Plan the search strategy to identify the "current best evidence" relevant to the question. The plan for identification and inclusion of articles and reports should be systematic and reproducible, not haphazard. Write out the original search strategy and document adjustments to the strategy if they occur. Allow for several iterations of searches.
2. List inclusion and exclusion criteria. The work group will define the inclusion and exclusion criteria. These criteria will be used in defining the search strategy and for filtering the identified research reports. ADA uses only peer-reviewed research; that is, articles accepted for evidence analysis must be peer-reviewed and published in a juried publication. Additionally, ADA only uses human subjects in its research and does not include animal studies in its evidence analysis.
3. Identify search words. During the process of considering outcomes, interventions, nutrition diagnoses, and assessments, the work group may have identified a number of specific terms or factors that were important, but were not included in the actual question. These terms can be used as additional search terms to help identify relevant pieces of research. Both text word search and keyword search using Medical Subject Headings (MeSH) definitions may be used.
4. Identify databases to search. PubMed, Medline, CINAHL, EMBASE, Cochrane, Agricola, DARE, TRIP, AHRQ and ERIC are some common databases for clinical nutritional research. Note that search terms can vary depending on the database.
5. Conduct the search. Depending on the number and type of sources found in the initial search, adjustments might have to be made in the search strategy and to inclusion/exclusion criteria, and additional searches run. Changes to the search plan should be recorded for future reference. Document the number of sources identified in each search.
6. Review titles and abstracts. At this point, filtering procedure is used to determine whether a research article matches the inclusion criteria and is relevant to the work group's questions. Typically, the lead analyst, along with a member of the expert workgroup, first reviews the citations and abstracts to filter out reports that are not applicable to the question. If a determination cannot be made based on the citation and abstract, then the full text of the article is obtained for review.
7. Gather all remaining articles and reports. Obtain paper or electronic copies of research articles that remain on the list following the citation and abstract review. If there are less than six citations, it could mean that the search was too specific to identify relevant research or that research has not been done on this topic. A broadened search should be tried. When there is a long list of citations, ascertain whether it includes articles that are tangential to the question or address the question in only a general way. In this case a more focused search strategy may be necessary.

Specific Methods for This Guideline

The recommendations in the guideline were based on a systematic review of the literature. Searches of PubMed, CENTRAL, and CINAHL and hand searches of other relevant literature were performed on the following topics:

• Medical nutrition therapy and dietitian intervention
• Energy needs
• Protein needs
• Chronic kidney disease (CKD)-bone mineral disorder
• Anemia
• Diabetes
• Obesity
• Hypertension
• Disorders of lipid metabolism
• Physical activity
• Fish oil therapy

Each evidence analysis topic has a link to supporting evidence in the original guideline, where the Search Plan and Results can be found. Here the reader can view when the search plan was performed, specific inclusion and exclusion criteria, search terms, data bases that were searched, and the excluded articles.

The number of supporting documents for the recommendations is 24.

Conclusion Grading Table

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Step 1: Formulate Evidence Analysis Question

Specify a question in a defined area of practice; or state a tentative conclusion or recommendation that is being considered. Include the patient type and special needs of the target population involved, the alternatives under consideration, and the outcomes of interest (PICO format).

Step 2: Gather and Classify Evidence

Conduct a systematic search of the literature to find evidence related to the question, gather studies and reports, and classify them by type of evidence. Classes differentiate primary reports of new data according to study design, and distinguish them from secondary reports that include systematic and/or narrative review.

Step 3: Critically Appraise Each Article

Review each article for relevance to the question and use the checklist of questions to evaluate the research design and implementation. Abstract key information from the report.

Step 4: Summarize Evidence

Synthesize the reports into an overview table and summarize the research relevant to the question.

Step 5: Write and Grade the Conclusion Statement

Develop a concise conclusion statement (the answer to the question). Assign a grade to indicate the overall strength or weakness of evidence informing the conclusion statement (see "Rating Scheme for the Strength of the Evidence").

Moving From Analysis to the Evidence-Based Nutrition Practice Guideline

The expert workgroup, which includes practitioners and researchers with a depth of experience in the specific field of interest, develops the disease-specific guideline. The guideline development involves the following steps.

Review the Conclusion Statements

The workgroup meets to review the materials resulting from the evidence analysis, which may include review of the conclusion statements, evidence summaries and evidence worksheets.

Formulate Recommendations for the Guideline Integrating Conclusions from Evidence Analysis

The workgroup uses an expert consensus method to formulate the guideline recommendations and complete the various sections on the recommendation page. These include:

• Recommendation(s): This is a course of action for the practitioner. The recommendation is written using two brief and separate statements. The first statement is "what" the dietitian should do or not do? The second statement describes the "why" of the recommendation. More than one recommendation may be formulated depending on a particular topic and the supporting conclusion statements.
• Rating: The rating for the recommendation is based on the strength of the supporting evidence. The grade of the supporting conclusion statement(s) will be help determining this rating (see "Rating Scheme for the Strength of the Recommendation").
• Label of Conditional or Imperative: Each recommendation will have a label of "conditional" or "imperative". Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence.
• Risks and Harms of Implementing the Recommendation: Includes any potential risks, anticipated harms or adverse consequences associated with applying the recommendation(s) to the target population.
• Conditions of Application: Includes any organizational barriers or changes that would need to be made within an organization to apply the recommendation in daily practice. Also includes any conditions which may limit the application of the recommendation(s). For instance, application may be limited to only people in an inpatient setting, or not applicable for pregnant women. Conditional recommendations will always have conditions specified. Imperative recommendations may have some general conditions for application.
• Potential Costs Associated with Application: Includes any costs that may be associated with the application of this recommendation such as specialized staff, new equipment or treatments.
• Recommendation Narrative: Provides a brief description of the evidence that supports this recommendation.
• Recommendation Strength Rationale: Provides a brief list of the evidence strength and methodological issues that determined the recommendation strength.
• Minority Opinions: If the expert workgroup cannot reach consensus on the recommendation, the minority opinions may be listed here.
• Supporting Evidence: Provides links to the conclusions statements, evidence summaries and worksheets related to the formulation of this recommendation(s).
• References Not Graded in the American Dietetic Association's (ADA) Evidence Analysis Process: Recommendations will be based on the summarized evidence from the analysis. Sources that were not analyzed during the evidence analysis process may be used to support and formulate the recommendation or to support information under other categories on the recommendation page, if the workgroup deems necessary. References must be credible resources (e.g., consensus reports, other guidelines, position papers, standards of practice, articles from peer-reviewed journals, nationally recognized documents or websites). If recommendations are based solely on these types of references, they will be rated as "consensus."

  Occasionally recommendations will include references that were not reviewed during the evidence analysis process but are relevant to the recommendation, risks and harms of implementing the recommendation, conditions of application, or potential costs associated with application. These references will be listed on the recommendation page under "References Not Graded in ADA's Evidence Analysis Process."

Develop a Clinical Algorithm for the Guideline

The workgroup develops a clinical algorithm based on ADA's Nutrition Care Process, to display how each recommendation can be used within the treatment process and how they relate to the Nutrition Assessment, Diagnosis, Intervention, and Monitoring and Evaluation.

Complete the Writing of the Guideline

Each disease-specific guideline has a similar format which incorporates the Introduction (includes: Scope of the Guideline, Statement of Intent, Guideline Methods, Implementation, Benefits and Risks/Harms of Implementation), Background Information, and any necessary Appendices. The workgroup develops these features.

Criteria Used in Guideline Development

The criteria used in determining the format and process for development of ADA's guidelines is based on the following tools and criteria for evidence-based guidelines:

• Guideline Elements Model (GEM), which has been incorporated by the American Society for Testing and Materials (ASTM) as a Standard Specification for clinical practice guidelines.
• AGREE (Appraisal for Guidelines Research and Evaluation) Instrument
• National Guideline Clearinghouse (www.guideline.gov )

Criteria for Recommendation Rating

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Each guideline is reviewed internally and externally using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument as the evaluation tool. The external reviewers consist of a multidisciplinary group of individuals (may include dietitians, doctors, psychologists, nurses, etc.). The guideline is adjusted by consensus of the expert panel and approved by American Dietetic Association's Evidence-Based Practice Committee prior to publication on the Evidence Analysis Library (EAL).

Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion grades (I-V), and statement labels (Conditional versus Imperative) are defined at the end of the "Major Recommendations" field.

Chronic Kidney Disease (CKD) Medical Nutrition Therapy (Non-Dialysis)

CKD: Medical Nutrition Therapy

Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals with chronic kidney disease (CKD, Stages One to Five including post-kidney transplant). MNT prevents and treats protein-energy malnutrition and mineral and electrolyte disorders and minimizes the impact of other comorbidities on the progression of kidney disease (e.g., diabetes, obesity, hypertension and disorders of lipid metabolism). Studies regarding effectiveness of MNT report significant improvements in anthropometric and biochemical measurements sustained for at least one year.

Strong, Imperative

CKD: Initiation of Medical Nutrition Therapy

Referral for MNT per federal or state guidelines should be initiated at diagnosis of CKD, in order to maintain adequate nutritional status, prevent disease progression and delay renal replacement therapy (RRT). MNT should be initiated at least 12 months prior to the anticipation of RRT (dialysis or transplant).

Strong, Imperative

CKD: Frequency of Medical Nutrition Therapy

Depending on the care setting and the initiation of MNT, the RD should monitor the nutritional status of individuals with CKD every one to three months and more frequently if there is inadequate nutrient intake, protein-energy malnutrition, mineral and electrolyte disorders or the presence of an illness that may worsen nutritional status, as these are predictive of increased mortality risk. Research related to the time requirements for MNT provided by an RD indicate that approximately two hours per month for up to one year may be required to provide an effective intervention for adults with CKD.

Strong, Conditional

Recommendation Strength Rationale

• Conclusion statements were Grade I.
• The American Dietetic Association (ADA) CKD Expert Work Group concurs with the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. KDOQI group members accepted the guideline statements as valid if the median panel rating was seven or greater on a scale of one to nine.

CKD Assessment of Food/Nutrition-Related History

CKD: Initial Assessment of Food/Nutrition-Related History

The registered dietitian should assess the food- and nutrition-related history of adults with chronic kidney disease (including post kidney transplant), including but not limited to the following:

• Food and nutrient intake (e.g., diet history, diet experience and intake of macronutrients [and micronutrients, such as energy, protein, sodium, potassium, calcium, phosphorus, and others], as appropriate)
• Medication (prescription and over-the-counter), dietary supplements (vitamin, minerals, protein, etc.), herbal or botanical supplement use
• Knowledge, beliefs or attitudes (e.g., readiness to change nutrition and lifestyle behaviors)
• Behavior
• Factors affecting access to food and food and nutrition-related supplies (e.g., safe food and meal availability)

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.

Consensus, Imperative

CKD: Reassessment of Food/Nutrition-Related History

On subsequent visits, the RD should reassess the food- or nutrition-related history of adults with CKD (including post kidney transplant), related to changes in other assessment parameters (laboratory and anthropometric changes), including but not limited to the following:

• Food and nutrient intake, targeted to changes in biochemical parameters
• Medication, dietary supplements, herbal or botanical supplement use
• Knowledge, beliefs or attitudes
• Behavior
• Factors affecting access to food and food and nutrition-related supplies

Assessment of the above factors is needed to explain changes in the other assessment parameters and plan additional nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.

Consensus, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.

CKD Anthropometric Assessment Options

CKD: Use Clinical Judgment in Assessing Body Weight

Due to the absence of standard reference norms in the chronic kidney disease population (CKD, including post kidney transplant), the registered dietitian should use clinical judgment to determine which data to include in estimations of body weight:

• Actual measured weight
• History of weight changes (both long-term and recent)
• Serial weight measurements, monitored longitudinally
• Adjustments for suspected impact of edema, ascites and polycystic organs

Body weight estimates are used for calculation of nutritional needs, such as protein and energy requirements. Body weight can be difficult to determine because as kidney function declines, the ability to regulate fluid balance may be compromised and multiple factors must be considered.

Consensus, Imperative

CKD: Use Published Weight Norms with Caution

The RD may use other published weight norms in the anthropometric assessment of individuals with CKD (including post kidney transplant), but each norm has significant drawbacks and must be used with caution:

• Ideal body weight (IBW) is the body weight associated with the lowest mortality for a given height, age, sex and frame size and is based on the Metropolitan Life Insurance Height and Weight Tables. (Caution: Not generalizable to the CKD population and data-gathering methods were not standardized.)
• Hamwi Method determines the optimal body weight. (Caution: A quick and easy method for determining optimal body weight, but has no scientific data to support its use.)
• Standard Body Weight, National Health and Nutrition Examination Survey (NHANES II) (SBW as per KDOQI Nutrition Practice Guidelines) describes the median body weight of average Americans from 1976 to 1980 for height, age, sex and frame size. (Caution: Although data is validated and standardized and uses a large database of ethnically-diverse groups, data is provided only on what individuals weigh, not what they should weigh in order to reduce morbidity and mortality.)
• Body Mass Index (BMI) often defines generalized obesity and CKD research, specific to dialysis patients, has identified that patients at higher BMIs have a lower mortality risk. (Caution: The researchers may not have statistically adjusted for all confounders related to comorbid conditions occurring in CKD on dialysis [diabetes, malignancy, etc.] and it is unclear how it may relate to CKD patients not on dialysis.)
• Adjusted Body Weight (ABW) is based on the theory that 25% of the excess body weight (adipose tissue) in obese patients is metabolically active tissue. KDOQI supports the concept of subtracting 25% for obese patients and adding 25% for underweight patients. (Caution: This has not been validated for use in CKD and may either overestimate or underestimate energy and protein requirements.)

Body weight estimates are used for calculation of nutritional needs, such as protein and energy requirements. Body weight can be difficult to determine because as kidney function declines, the ability to regulate fluid balance may be compromised and multiple factors must be considered.

Consensus, Conditional

CKD: Assessment of Body Composition

The RD should assess the body composition of individuals with CKD (including post kidney transplant). Studies suggest that CKD patients exhibit altered body composition, as compared to healthy individuals.

Fair, Imperative

CKD: Methodologies for Body Composition Assessment

When assessing the body composition of individuals with CKD (including post kidney transplant), the RD may use any valid measurement methodology, such as anthropometrics (including waist circumference and body mass index) and body compartment estimates. Currently, there is no reference standard for assessing body composition in CKD patients and studies do not show that any one test is superior to another in assessing body composition among CKD patients.

Fair, Imperative

Recommendation Strength Rationale

• Conclusion statement was Grade II.
• The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.

CKD Assessment of Biochemical Parameters

CKD: Assess Biochemical Parameters

The RD should assess various biochemical parameters in adults with chronic kidney disease (including post-kidney transplant), related to:

• Glycemic control
• Protein-energy malnutrition
• Inflammation
• Kidney function
• Mineral and bone disorders
• Anemia
• Dyslipidemia
• Electrolyte disorders
• Others as appropriate

Assessment of the above factors is needed to effectively determine the nutrition diagnoses and nutrition prescription in adults with CKD and post-kidney transplant.

Consensus, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:

• Nutrition in Chronic Renal Failure
• Bone Metabolism and Disease in Chronic Kidney Disease
• Anemia in Chronic Kidney Disease

CKD Assess CKD-Mineral and Bone Disorders

CKD: Assess CKD-Mineral and Bone Disorders

The RD should assess measurements of mineral and bone disorders (MBD) in adults with chronic kidney disease (including post kidney transplant) for prevention and treatment. Adults with CKD have altered mineral-bone metabolism and increased risk of vascular disease.

Consensus, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease.

CKD Assessment of Medical/Health History

CKD: Assessment of Medical/Health History

When implementing MNT, the RD should assess the medical and health history of individuals with CKD (including post kidney transplant) for the presence of other disease states and conditions, such as diabetes, hypertension, obesity and disorders of lipid metabolism. Adults with CKD, including post kidney transplant, have a higher prevalence of comorbidities, which are risk factors for the progression of kidney disease.

Strong, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:

• Hypertension and Antihypertensive Agents in Chronic Kidney Disease
• Managing Dyslipidemias in Chronic Kidney Disease
• Diabetes and Chronic Kidney Disease

CKD Protein Intake

CKD: Protein Intake for Estimated Glomerular Filtration Rate (eGFR) <50 ml per minute per 1.73m²

For adults with CKD without diabetes, not on dialysis, with eGFR below 50ml per minute per 1.73m², the RD should recommend or prescribe a protein-controlled diet providing 0.6 g to 0.8 g dietary protein per kg of body weight per day. Clinical judgment should be used when recommending lower protein intakes, considering the client's level of motivation, willingness to participate in frequent follow-up and risk for protein-energy malnutrition. Research reports that protein-restricted diets (0.7 g dietary protein per kg of body weight per day, ensuring adequate caloric intake) can slow GFR decline and maintain stable nutrition status in adult non-diabetic patients with CKD.

Strong, Conditional

CKD: Very-Low-Protein Intake for eGFR <20 ml per minute per 1.73m²

In international settings where keto acid analogs are available, a very-low protein-controlled diet may be considered. For adults with CKD without diabetes, not on dialysis, with an eGFR below 20 ml per minute per 1.73m², a very-low protein-controlled diet providing 0.3 g to 0.5 g dietary protein per kg of body weight per day with addition of keto acid analogs to meet protein requirements may be recommended. International studies report that additional keto acid analogs and vitamin or mineral supplementation are needed to maintain adequate nutrition status for patients with CKD who consume a very-low-protein controlled diet (0.3 g to 0.5 g per kg per day).

Strong, Conditional

CKD: Protein Intake for Diabetic Nephropathy

For adults with diabetic nephropathy, the RD should recommend or prescribe a protein-controlled diet providing 0.8 g to 0.9 g of protein per kg of body weight per day. Providing dietary protein at a level of 0.7 g per kg of body weight per day may result in hypoalbuminemia. Research reports that protein-restricted diets improved microalbuminuria.

Fair, Conditional

CKD: Protein Intake for Kidney Transplant

For adult kidney transplant recipients (after surgical recovery, with an adequately functioning allograft), the RD should recommend 0.8 g to 1.0 g per kg of body weight per day for protein intake, addressing specific issues as needed. Adequate, but not excessive, protein intake supports allograft survival and minimizes impact on comorbid conditions.

Consensus, Conditional

Recommendation Strength Rationale

• For the CKD: Protein Intake (Non-dialysis) for eGFR <50 ml per minute per 1.73m² recommendation, the conclusion statement was Grade I.
• For the CKD: Very-Low-Protein Intake (Non-dialysis) for eGFR <20 ml per minute per 1.73m² recommendation, the conclusion statement was Grade I.
• For the CKD: Protein Intake for Diabetic Nephropathy recommendation, the conclusion statement was Grade II.
• For the CKD: Protein Intake for Kidney Transplant recommendation, the conclusion statement was Grade III.

CKD Energy Intake

CKD: Energy Intake

For adults with CKD (including post kidney transplant after surgical recovery), the RD should recommend or prescribe an energy intake between 23 kcal to 35 kcal per kg of body weight per day, based on the following factors:

• Weight status and goals
• Age and gender
• Level of physical activity
• Metabolic stressors

Research reports that energy intakes between 23 kcal to 35 kcal per kg body weight per day are adequate to prevent signs of malnutrition.

Fair, Imperative

Recommendation Strength Rationale

• Conclusion statement in support of this recommendation was Grade II.
• The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.

CKD Phosphorus

CKD: Phosphorus

For adults with CKD (Stages Three to Five), the RD should recommend or prescribe a low-phosphorus diet providing 800 mg to 1,000 mg per day or 10 mg to 12 mg phosphorus per gram of protein. CKD patients have a predisposition for mineral and bone disorders. Phosphorus control is the cornerstone for the treatment and prevention of secondary hyperparathyroidism, renal bone disease and soft tissue calcification.

Strong, Conditional

CKD: Adjust Phosphate Binders

For adults with CKD (Stages Three to Five), the dose and timing of phosphate binders should be individually adjusted to the phosphate content of meals and snacks to achieve desired serum phosphorus levels. Serum phosphorus levels are difficult to control with dietary restrictions alone.

Strong, Conditional

CKD: Phosphorus Management for Kidney Transplant

For adult kidney transplant recipients exhibiting hypophosphatemia, the RD should recommend or prescribe a high-phosphorus intake (diet or supplements) to replete serum phosphorus as needed. Hypophosphatemia is common post kidney transplant.

Consensus, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade II.
• The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease.

CKD Calcium

CKD: Calcium

For adults with CKD (Stages Three to Five, including post kidney transplant), the RD should recommend a total elemental calcium intake (including dietary calcium, calcium supplementation and calcium-based phosphate binders) not exceeding 2, 000 mg per day. CKD patients have a predisposition for mineral and bone disorders. Serum calcium concentration is the most important factor regulating parathyroid hormone (PTH) secretion affecting bone integrity and soft tissue calcification.

Consensus, Conditional

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease.

CKD Vitamin D Therapy

CKD: Vitamin D Supplementation

In adults with CKD (including post kidney transplant), the RD should recommend vitamin D supplementation to maintain adequate levels of vitamin D if the serum level of 25-hydroxyvitamin D is less than 30 ng per ml (75 nmol per L). CKD patients have a predisposition for mineral and bone disorders, as well as other conditions that may be affected by insufficient vitamin D. Sufficient vitamin D should be recommended to maintain adequate levels of serum vitamin D.

Consensus, Conditional

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease.

CKD Anemia

CKD: Iron Supplementation

In adults with CKD (including post kidney transplant), the RD should recommend oral or intravenous (IV) iron administration if serum ferritin is below 100 ng per ml and transferrin saturation (TSAT) is below 20%. CKD patients have a predisposition for anemia. Sufficient iron should be recommended to maintain adequate levels of serum iron to support erythropoiesis.

Consensus, Conditional

CKD: Vitamin B12 and Folic Acid for Anemia

In adults with CKD (including post kidney transplant), the RD should recommend vitamin B12 and folic acid supplementation if the mean corpuscular volume (MCV) is over 100 ng per ml and serum levels of these nutrients are below normal values. CKD patients have a predisposition for anemia and all potential causes should be investigated.

Consensus, Conditional

CKD: Vitamin C for Treatment of Anemia

If the use of vitamin C supplementation is proposed as a method to improve iron absorption for adults with CKD (including post kidney transplant) who are anemic, the RD should recommend the dietary reference intakes (DRI) for vitamin C. There is insufficient evidence to recommend the use of vitamin C supplementation above the DRI in the management of anemia in patients with CKD, due to risk of hyperoxalosis.

Consensus, Conditional

CKD: L-Carnitine for Treatment of Anemia

For adults with CKD (including post kidney transplant) who are anemic, the RD should not recommend L-carnitine supplementation. There is insufficient evidence to recommend the use of L-carnitine in the management of anemia in adults with CKD including post kidney transplant.

Consensus, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade II.
• The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Anemia in Chronic Kidney Disease.

CKD Management of Hyperglycemia in Diabetes and CKD

CKD: Management of Hyperglycemia in Diabetes and CKD

For adults with diabetes and CKD (including post kidney transplant), the RD should implement MNT for diabetes care to manage hyperglycemia to achieve a target A1C of approximately 7%. Intensive treatment of hyperglycemia, while avoiding hypoglycemia, prevents diabetic kidney disease (DKD) and may slow progression of established kidney disease.

Strong, Conditional

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease.

CKD Multi-Faceted Approach to Intervention in Diabetes and CKD

CKD: Multi-Faceted Approach to Intervention in Diabetes and CKD

For adults with diabetes and CKD (including post kidney transplant), the RD should implement MNT using a multi-faceted approach, including education and counseling in healthy behaviors, treatment to reduce risk factors and self-management strategies. Multiple risk factors are managed concurrently in adults with diabetes and CKD and the incremental effects of treating each of these risk factors results in substantial clinical benefits.

Consensus, Conditional

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease.

CKD Multi-Faceted Approach to Intervention in Dyslipidemias and CKD

CKD: Multi-Faceted Approach to Intervention in Dyslipidemias and CKD

For adults with dyslipidemia and CKD (including post kidney transplant), the RD should implement MNT, using a multi-faceted approach, including education and counseling in therapeutic lifestyle changes (TLC), treatment to reduce risk factors and self-management strategies. Multiple risk factors are managed concurrently in adults with dyslipidemia and CKD and the incremental effects of treating each of these risk factors results in substantial clinical benefits.

Fair, Conditional

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:

• Managing Dyslipidemias in Chronic Kidney Disease
• Diabetes and Chronic Kidney Disease

CKD Education on Self-Management Behaviors

CKD: Education on Self-Management Behaviors

For individuals with CKD (including post kidney transplant), the RD should provide education and counseling regarding self-management behaviors. Therapy must take into consideration the patient's perception of the health-care provider's advice and prescriptions, factors that may influence self-management behaviors and the likelihood that the patient will adhere to recommendations.

Fair, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease.

CKD Sodium

CKD: Control Sodium Intake in CKD

For adults with CKD (including post-kidney transplant) the RD should recommend/prescribe a sodium intake of less than 2.4 g (Stages One to Five), with adjustments based on the following:

• Blood pressure
• Medications
• Kidney function
• Hydration status
• Acidosis
• Glycemic control
• Catabolism
• Gastrointestinal issues, including vomiting, diarrhea and constipation

Dietary and other therapeutic lifestyle modifications are recommended as part of a comprehensive strategy to reduce cardiovascular disease risk in adults with CKD.

Fair, Imperative

Recommendation Strength Rationale

• Conclusion statement received Grade II.
• The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease and the Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease.

CKD Fish Oil/Omega-3 Fatty Acids

CKD: Fish Oil/Omega-3 Fatty Acids

If the use of fish oil or omega-3 fatty acid supplementation is proposed as a method to improve renal function, the RD should advise on the conflicting evidence regarding effectiveness of this strategy. Research reports that renal outcomes were inconsistent among patients with immunoglobulin A (IgA) nephropathy who received fish oil supplementation. There is insufficient evidence to support fish oil therapy to improve renal function and patient or graft survival for kidney transplant patients. However, evidence does support a benefit of fish oil supplementation in reducing oxidative stress and improving lipid profile in adults with CKD (including post kidney transplant).

Fair, Conditional

Recommendation Strength Rationale

Conclusion statements were Grades II and III.

CKD Physical Activity

CKD: Physical Activity

If not contraindicated, the RD should encourage adults with CKD (including post kidney transplant), to increase frequency or duration of physical activity as tolerated. Studies report that physical activity may minimize the catabolic effects of protein restriction and improve quality of life.

Fair, Conditional

Recommendation Strength Rationale

Conclusion statements were Grade III.

CKD Coordination of Care

CKD: Coordination of Care

For adults with CKD (including post kidney transplant), the RD should implement MNT and coordinate care with an interdisciplinary team, through:

• Requesting appropriate data (biochemical and other)
• Communicating with referring provider
• Indicating specific areas of concern or needed reinforcement.

This approach is necessary to effectively integrate MNT into overall management for patients with CKD.

Consensus, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.

CKD Multivitamin Supplementation

CKD: Multivitamin Supplementation

In adults with CKD (including post kidney transplant), with no known nutrient deficiency (biochemical or physical) and who may be at higher nutritional risk due to poor dietary intake and decreasing GFR, the RD should recommend or prescribe a multivitamin preparation. Sufficient vitamin supplementation should be recommended to maintain indices of adequate nutritional status.

Consensus, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade III.
• The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease.

CKD Potassium

CKD: Control Potassium Intake in CKD

For adults with CKD (including post kidney transplant) who exhibit hyperkalemia, the RD should recommend or prescribe a potassium intake of less than 2.4 g (Stages Three to Five), with adjustments based on the following:

• Serum potassium level
• Blood pressure
• Medications
• Kidney function
• Hydration status
• Acidosis
• Glycemic control
• Catabolism
• Gastrointestinal (GI) issues, including vomiting, diarrhea, constipation and GI bleed

Dietary and other therapeutic lifestyle modifications are recommended as part of a comprehensive strategy to reduce cardiovascular disease risk in adults with CKD. The degree of hypokalemia or hyperkalemia can have a direct effect on cardiac function, with potential for cardiac arrhythmia and sudden death.

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade II.
• The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease and the Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease.

CKD Monitor and Evaluate Biochemical Parameters

CKD: Monitor and Evaluate Biochemical Parameters

The RD should monitor and evaluate various biochemical parameters in adults with CKD (including post kidney transplant), related to:

• Glycemic control
• Protein-energy malnutrition
• Inflammation
• Kidney function
• Mineral and bone disorders
• Anemia
• Dyslipidemia
• Electrolyte disorders
• Others as appropriate

Monitoring and evaluation of the above factors is needed to determine the effectiveness of MNT in adults with CKD and post kidney transplant.

Consensus, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:

• Nutrition in Chronic Renal Failure
• Bone Metabolism and Disease in Chronic Kidney Disease
• Anemia in Chronic Kidney Disease

CKD Monitor and Evaluate Adherence to Nutrition and Lifestyle Recommendations

CKD: Monitor and Evaluate Adherence to Nutrition and Lifestyle Recommendations

The RD should monitor the following in adults with CKD (including post kidney transplant):

• Food and nutrient intake (e.g., diet history, diet experience and intake of macronutrients and micronutrients, such as energy, protein, sodium, potassium, calcium, phosphorus and others, as appropriate)
• Medication (prescription and over-the-counter), dietary supplements (vitamin, minerals, protein, etc.), herbal or botanical supplement use
• Knowledge, beliefs or attitudes (e.g., readiness to change nutrition and lifestyle behaviors)
• Behavior
• Factors affecting access to food and food- and nutrition-related supplies (e.g., safe food and meal availability)

Monitoring and evaluation of the above factors is needed to determine the effectiveness of MNT in adults with CKD and post kidney transplant.

Consensus, Imperative

Recommendation Strength Rationale

The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.

Definitions:

Conditional versus Imperative Recommendations

Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence. More specifically, a conditional recommendation can be stated in if/then terminology (e.g., If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention).

In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain conditional text that would limit their applicability to specified circumstances. (e.g., Portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss).

Conclusion Grading Table

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.

Criteria for Recommendation Rating

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.

Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.

Algorithms are provided in the original guideline document for:

• Chronic Kidney Disease (CKD) Nutrition Guideline
• CKD Nutrition Assessment
• CKD Nutrition Diagnosis
• CKD Nutrition Intervention
• CKD Nutrition Monitoring and Evaluation

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The guideline contains conclusion statements that are supported by evidence summaries and evidence worksheets. These resources summarize the important studies (randomized controlled trials [RCTs], clinical trials, observational studies, cohort and case-control studies) pertaining to the conclusion statement and provide the study details.

Risk/Harm Considerations

When using these recommendations:

• Review the patient's age, socioeconomic status, cultural issues, health history, and other health conditions.
• Consider referral to a behavioral specialist if psychosocial issues are a concern.
• Consider a referral to social services to assist patients with financial arrangements if economic issues are a concern.
• Use clinical judgment in applying the guidelines when evaluating adults with chronic kidney disease.

In addition to the above, a variety of barriers may hinder the application of these recommendations:

• Lower protein and energy intakes can lead to hypoalbuminemia, malnutrition, loss of lean body mass and unintentional weight loss.
• For chronic kidney disease (CKD) patients with hypophosphatemia or hyperphosphatemia, the registered dietitian (RD) should be aware that protein-controlled diets are typically lower in phosphorus content and therefore protein intake may affect phosphorus management. Hypophosphatemia and hyperphosphatemia are associated with increased morbidity and mortality.
• The RD should be aware of the risks of hypercalcemia, such as soft tissue calcification, altered mental status, tetany, cardiac events and other adverse effects.
• Oral iron supplementation may result in gastrointestinal distress and lack of adherence to regime. Iron absorption may be impaired by other medications, including phosphate binders, other iron and supplements.
• Excessive intake of vitamin C may result in hyperoxalosis and contribute to the formation of calcium oxalate kidney stones.
• Intensive treatment of hyperglycemia may result in more frequent episodes of hypoglycemia.
• A nutrition prescription that is too high or too low in sodium may result in adverse outcomes.
• The dietitian should be aware that fish oil therapy provided at the levels given in the studies can affect the ability of the blood to coagulate and may be additive to the effects of anticoagulant therapy. Patient tolerance, adherence or allergies may be factors in maintaining a fish oil supplementation regimen.
• Before beginning a program of physical activity more vigorous than brisk walking, individuals with CKD should be assessed for conditions that might be associated with an increased risk of cardiovascular disease and other physical conditions that may be adversely affected. Intense physical activity in adults with CKD may contribute to disability or death, thus consultation with a physician prior to beginning an exercise program should be recommended.
• Intakes of multivitamin supplementation above 100% of the dietary reference intakes (DRI) for an individual may result in adverse effects.
• A nutrition prescription that is too high or too low in potassium may result in adverse outcomes.

Bone density assessment may be contraindicated in pregnancy.

Description of Implementation Strategy

The publication of this guideline is an integral part of the plans for getting the American Dietetic Association Medical Nutrition Therapy (ADA MNT) evidence-based recommendations on chronic kidney disease (CKD) to all dietetics practitioners engaged in teaching about or researching this topic. National implementation workshops at various sites around the country and during the ADA Food Nutrition Conference Expo (FNCE) are planned. Additionally, there are recommended dissemination and adoption strategies for local use of the ADA CKD Evidence-Based Nutrition Practice Guideline.

The guideline development team recommended multi-faceted strategies to disseminate the guideline and encourage its implementation. Management support and learning through social influence are likely to be effective in implementing guidelines in dietetic practice. However, additional interventions may be needed to achieve real change in practice routines.

Implementation of the guideline will be achieved by announcement at professional events, presentations and training. Some strategies include:

• National and local events: State dietetic association meetings and media coverage will help launch the guideline.
• Local feedback adaptation: Presentation by members of the work group at peer review meetings and opportunities for continuing education units (CEUs) for courses completed
• Education initiatives: The guideline and supplementary resources will be freely available for use in the education and training of dietetic interns and students in approved Commission on Accreditation of Dietetics Education (CADE) programs.
• Champions: Local champions will be identified and expert members of the guideline team will prepare articles for publications. Resources will be provided that include PowerPoint presentations, full guidelines and pre-prepared case studies.
• Practical Tools: Some of the tools that will be developed to help implement the guideline include specially-designed resources, such as clinical algorithms, slide presentations, training and toolkits.

Specific distribution strategies include:

Publication in full: The guideline is available electronically at the ADA Evidence Analysis Library website (www.adaevidencelibrary.com ) and announced to all ADA Dietetic Practice Groups. The ADA Evidence Analysis Library will also provide downloadable supporting information and links to relevant position papers.

Not applicable: The guideline was not adapted from another source.

American Dietetic Association

American Dietetic Association Chronic Kidney Disease (CKD) Expert Work Group

Work Group Members: Jessie Pavlinac, MS, RD, CSR, LD, Chair; Arianna Aoun, MS, RD, CSR, LD; Laura Byham-Gray, PhD, RD; Carolyn Cochran, MS, RD, LD, CDE; Barbara Hutson, RD, LD; Joni Pagenkemper, MS, MA, RD, LMNT, CDE

In the interest of full disclosure, American Dietetic Association (ADA) has adopted the policy of revealing relationships workgroup members have with companies that sell products or services that are relevant to this topic. Workgroup members are required to disclose potential conflicts of interest by completing the ADA Conflict of Interest Form. It should not be assumed that these financial interests will have an adverse impact on the content, but they are noted here to fully inform readers. Users of the evidence analysis library may assume that only work group members listed below have potential conflicts of interest to disclose.

None of the work group members disclosed potential conflicts of interest.

This is the current release of the guideline.

This guideline updates a previous version: American Dietetic Association. Chronic kidney disease (non-dialysis) medical nutrition therapy protocol. Chicago (IL): American Dietetic Association; 2002 May. Various p.

Electronic copies: Available from the American Dietetic Association Web site .

The following are available:

• American Dietetic Association (ADA) chronic kidney disease (CKD) evidence-based nutrition practice guideline. Executive summary of recommendations. Chicago (IL): American Dietetic Association. 2010. Electronic copies: Available from the ADA Web site .
• ADA chronic kidney disease (CKD) evidence-based nutrition practice guideline presentation. Slide set. 2010. 64 p. Chicago (IL): American Dietetic Association. Electronic copies: Available for purchase from the ADA Web site .

None available

This NGC summary was completed by ECRI on April 29, 2003. The information was verified by the guideline developer on August 6, 2003. This summary was updated by ECRI on January 29, 2007, following the U.S. Food and Drug Administration (FDA) advisory on erythropoiesis stimulating agents. This summary was updated by ECRI Institute on July 9, 2007, following the FDA advisory on erythropoiesis stimulating agents. This summary was updated by ECRI Institute on December 16, 2010.

The American Dietetic Association encourages the free exchange of evidence in nutrition practice guidelines and promotes the adaptation of the guidelines for local conditions. However, please note that guidelines are subject to copyright provisions. To replicate or reproduce this guideline, in part or in full, please obtain agreement from the American Dietetic Association. Please contact Kari Kren at kkren@eatright.org for copyright permission.

When modifying the guidelines for local circumstances, significant departures from these comprehensive guidelines should be fully documented and the reasons for the differences explicitly detailed.