Your renal practitioners/department editors have chosen three typical situations you might encounter in practice.
• Nutrition and diet help control kidney disease, but also heart disease, diabetes, and other comorbid states.
• Renal patients, like many others, often require surgeries; what specific concerns exist for surgical patients requiring dialysis?
• The Medicare education benefit has been a particular bonus for advanced practitioners, as we teach many of the classes.
We welcome your questions and comments.
Q: What is the renal diet? Should my patients with chronic kidney disease (CKD) restrict their protein consumption?
The CKD nondialysis diet aims to preserve remaining kidney function. A person living with kidney disease can continue to enjoy a variety of foods, including whole grains, fruits, and vegetables. These foods must be restricted only when phosphorus, parathyroid hormone, and/or potassium levels become elevated. However, many advanced practitioners recommend avoiding dark sodas because of their high phosphorus content. Sodium is limited to help maintain blood pressure control and decrease fluid buildup.
Fluid intake is not restricted unless fluid retention becomes an issue. Adequate caloric intake from carbohydrates and healthy fats is essential so as to spare protein for growth and repair. Aiming for a healthy weight through appropriate caloric intake and regular physical activity is important. A water-soluble vitamin B complex and a vitamin C supplement may be recommended as the diet becomes more restrictive. Supplemental vitamin D requirements and iron needs are based on findings from laboratory studies.
As is always the case when advising patients on food choices, the emphasis should be on optimizing nutrition and avoiding empty calories. A review of how to interpret a food label is often helpful to patients and their families.
Dietary protein recommendations continue to be controversial in CKD stages 1 through 4 (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2). The renal diet emphasizes high-quality proteins but limits protein intake to approximately 0.6 to 0.8 g/kg/d so as to decrease the workload on the kidneys and reduce urea waste production. The National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF-K/DOQI) Clinical Practice Guidelines for nutrition in patients with CKD1 recommend that patients who have an eGFR between 25 and 55 mL/min/1.73 m2 should eat at least 0.8 g/kg/d of protein; and that those whose eGFR is less than 25 mL/min/1.73 m2 and who are not receiving dialysis consume 0.6 g/kg/d. If a patient cannot tolerate the diet or is unable to maintain an adequate caloric intake, then protein intake can be 0.75 g/kg/d.
Once a patient is undergoing dialysis, the protein requirements may change, depending on the patient’s needs and type of dialysis. Fortunately, the renal dietician, an essential member of the interdisciplinary dialysis team, offers great assistance to the advanced practitioner in addressing the patient’s nutritional needs.
However, referral to a renal dietitian is recommended before dialysis, as diet is an important part of CKD treatment. A Medicare recipient with stage 3 or 4 CKD can see a registered dietitian through the Medical Nutrition Therapy benefit.2
Individualizing nutritional therapy is essential to optimize health in people living with the complexities of CKD. It is also very important, when assessing, monitoring, and intervening to avoid or treat malnutrition in these patients, to provide care as an interprofessional team that includes a renal dietician. (To provide the best evidence available, an experienced renal dietician was asked to contribute to this response.)
Debra Hain, PhD, APRN, GNP-BC
Assistant Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton; Nurse Practitioner, Cleveland Clinic Florida, Weston
Susan Meese-Morris, RD, LD/N
Renal Dietitian, Pine Island, Weston, and Miramar, Florida
Q: We scheduled a total knee replacement for a patient on dialysis, and anesthesia balked because the patient had a potassium level of 5.5 mEq/L. The nephrology practice, apparently not concerned, agreed to dialyze the patient, but only because anesthesia insisted. If the practice uses our facility, where 5.3 mEq/L is the upper limit of serum potassium, how can a potassium level of 5.5 mEq/L not be of concern in a hemodialysis patient?
This is a question that occurs frequently regarding patients receiving dialysis. Hyperkalemia is a problem faced by many dialysis patients as a result of the kidneys’ inability to remove potassium with the loss of renal function. Patients’ potassium levels are monitored routinely, and low-potassium diets are a staple of any nephrology clinic or dialysis unit.
For patients in our dialysis unit, the normal potassium range is 3.5 to 6.0 mEq/L, which is 0.9 mEq/L higher than for a patient without end-stage renal disease (ESRD). Dialysis patients with ESRD often have an increased tolerance for hyperkalemia.
When potassium levels are elevated, a 12-lead ECG is used to detect any physiological cardiac changes. These are generally not seen until the serum potassium exceeds 6.0 to 6.5 mEq/L. ECG changes seen in hyperkalemia include peaked T waves, a prolonged PR interval, and absent P waves with a widened QRS complex. These changes, which can lead to ventricular tachycardia or ventricular fibrillation, are not based on numbers or values of serum potassium, but are thought to reflect the transcellular potassium gradient.3
When questioning a potassium level in a dialysis patient and considering whether presurgical dialysis is needed, it is important to consider the surgery planned. In surgeries during which potassium might be released secondary to tissue trauma, potassium levels can rise higher during surgery.3
It is important to assess hypokalemia as well. Arrhythmias such as premature atrial and ventricular beats, sinus bradycardia, paroxysmal atrial or junctional tachycardia, atrioventricular block, and ventricular tachycardia or fibrillation can occur with hypokalemia. ECG changes include depression of the ST segment, a decrease in the amplitude of the T wave, and an increase in the amplitude of U waves, which occur at the end of the T wave. U waves are often seen in the lateral precordial leads V4 to V6.3
Laura MacGregor, RN, MS, NP-C
Grand Street Medical Associates, Kingston, New York
Q: Our practice received a flyer for kidney disease education classes offered by the local nephrology group. Can you tell me more about these classes?
Patient education in kidney disease has been shown to delay disease progression and improve patient outcomes.4 Because of this, the Medicare Improvements for Patients and Providers Act (MIPPA) of 20085 provided for classes for patients with stage 4 CKD (GFR, 15 to 29 mL/min/1.73 m2) to receive six hours of education over their lifetime.
Classes can be taught by a physician or an advanced practitioner (a PA, an NP, or a clinical nurse specialist). Four broad areas are covered: management of comorbidities that occur with CKD; prevention of complications, including an explanation of how the kidneys work and a review of medications; renal replacement modalities, including hemodialysis, peritoneal dialysis, and transplantation; and opportunities to empower the patients as active partners in their own health care.6 Classes also include information on managing anemia, hypertension, and bone mineral disease.7
Class structure is up to the provider. Most practices offer classes to all stage 4 CKD patients, regardless of Medicare status. Classes can be taught on a one-to-one basis or in a group setting.8
Some practices design their own format, while others use programs designed for CKD education. The National Kidney Foundation developed a slide set called Your Treatment, Your Choice,8 while the Cleveland Clinic, the Mayo Clinic, and the University of Alabama at Birmingham (among others, no doubt), have developed their own in-house programs. All these programs have a prepared Power Point slide deck, and most include evaluation tools.
Tricia Howard, MHS, PA-C
South University, Savannah, Georgia
REFERENCES
1. National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF-K/DOQI) Clinical Practice Guidelines for Nutrition in Chronic Renal Failure (2000). www.kidney.org/professionals/kdoqi/guidelines_updates/doqi_nut.html. Accessed February 16, 2012.
2. Medicare.gov. Medical nutrition therapy. www.medicare.gov/navigation/manage-your-health/preventive-services/medical-nutrition-therapy.aspx?AspxAutoDetectCookieSupport=1. Accessed February 16, 2012.
3. Soundararajan R, Golper T. Medical management of the dialysis patient undergoing surgery. www.uptodate.com/contents/medical-management-of-the-dialysis-patient-undergoing-surgery. Accessed February 16, 2012.
4. Young HN, Chan MR, Yevzlin AS, Becker BN. The rationale, implementation and effects of the Medicare CKD education benefit. Am J Kidney Dis. 2011;57(3):381-386.
5. H. R. 6331: Medicare Improvements for Patients and Providers Act of 2008. www.govtrack.us/congress/bill.xpd?bill=h110-6331. Accessed February 16, 2012.
6. §410.48. Kidney disease education services. Federal Register. 2009;74(226):62003.
7. Lazarus JM. National health care policy and its effect on renal care. Presented at: NKFI Multi-Disciplinary Conference; September 24, 2009; Chicago, IL.
8. National Kidney Foundation. MIPPA Kidney Disease Education Benefit. Your Treatment, Your Choice (2010). www.kidney.org/professionals/KLS/YTYC.cfm. Accessed February 16, 2012.