Medical Nutrition Therapy for CKD

 

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Medical nutrition therapy (MNT) or dietary counseling in chronic kidney disease (CKD), provided by a registered dietitian (RD), is critical for patients with CKD. It may improve health outcomes, enhance quality of life, and help delay kidney disease progression (1). Additionally, MNT may help prevent or treat complications, including malnutrition, metabolic acidosis, hyperkalemia, mineral imbalance/bone disorders, anemia, and cardiovascular disease (2).

However, despite its benefits, MNT is underutilized for patients with CKD. Although Medicare provides coverage for 3 hours in the first year and 2 hours in subsequent years, as of 2008 only 9486 RD Medicare providers enrolled (3) and fewer than 4 percent of CKD patients received at least 12 months of MNT prior to developing end stage renal disease (4).

To increase use of MNT for CKD patients, the National Kidney Disease Education Program (NKDEP) developed the CKD Diet Initiative. NKDEP started the effort by conducting roundtable discussions, in-depth interviews, and focus groups with RDs to better understand the barriers that limit their ability to counsel CKD patients. Through this research, NKDEP uncovered several barriers. RDs reported receiving limited referrals for CKD MNT and recommended educating primary care providers on the importance of MNT for CKD (5). In addition, many RDs—despite seeing more and more CKD patients—felt ill-equipped to counsel CKD patients due to insufficient training and a lack of both professional and patient education materials (6). Based on this research, NKDEP developed strategies for the CKD Diet Initiative to meet these needs. The initiative provides simplified and accessible professional and patient education materials on CKD nutrition, tools to increase CKD MNT referral by primary care providers, and training and education on counseling CKD patients for general practice RDs.

Since its inception, the CKD Diet Initiative has made significant progress. NKDEP has developed numerous professional and patient education materials for the practicing RD. These include the Chronic Kidney Disease and Diet: Assessment, Management, and Treatment guide and a suite of easy to read English- and Spanish-language patient education materials. NKDEP developed the CKD Diet Counseling Referral Form to support MNT referral by primary care providers. The referral form helps providers share critical patient data with the consulting RD. These materials have become immensely popular. Each month, thousands are downloaded and ordered.

In addition, NKDEP developed the CKD Nutrition Management Training Program. The program includes a series of five training modules that feature engaging activities and case studies. Each module focuses on a specific area of nutrition management for kidney disease patients, including background information on CKD, slowing the progression of CKD, CKD complications, the CKD “diet,” and the transition from CKD to kidney failure. The modules are available on the NKDEP website. NKDEP shared the content of the modules with the Academy of Nutrition and Dietetics (the Academy). The Academy developed the modules into an online training certificate program. By completing the module series and accompanying exams, RDs can earn 12.5 continuing education credits from the Academy. In the 2 and a half years since the launch of the training program, over 900 RDs have completed at least one module and 254 have completed all five and received a certificate of training in CKD nutrition management.

The Academy is evaluating the five-module continuing education program through a two-part survey and sharing the data with NKDEP. A survey immediately post-training assesses RD perceptions of program quality and a second survey that is fielded at least 6 months post-training assesses reported behavior change among RDs. In the first year, responses to the first survey have been analyzed for 52 program participants. Of these, the vast majority of surveyed participants have reported knowledge gains (94 percent), increased confidence (84 percent), and intent to change behavior around CKD MNT (71 percent) as a result of the program. Responses to the second survey have been analyzed for 14 participants who reported changes to their clinical practice (86 percent) as a result of the program. The program remains available for continuing education credit through the Academy, and participants who complete the module series are still receiving surveys. NKDEP intends to continue evaluation efforts as additional data are collected. Additionally, NKDEP will revise the module series based on RD feedback and update it to reflect the latest data and evidence.

To enhance the training of CKD nutrition for dietetic students and interns, NKDEP created a set of materials to support dietetic educators in teaching students and interns about managing nutrition for patients with CKD. The materials include a slide deck for use in the classroom and four case studies representing patients in different stages of progressive CKD This spring, NKDEP is once again collaborating with the Academy and “educating the educators” by presenting how to use the materials with follow-up webinars discussing the cases. For more information on the NKDEP diet program, visit http://nkdep.nih.gov/identify-manage/ckd-nutrition.shtml.

Notes

[1] Andrew S. Narva, MD, FACP, FASN, is director of the National Kidney Disease Education Program of the National Institute of Diabetes and Digestive and Kidney Diseases. Jenna Norton, MPH, is affiliated with the National Kidney Disease Education Program in Bethesda, MD.

References

1. Centers for Medicare & Medicaid Services. The Guide to Medicare Preventive Service, 4th ed. March 2011. ICN 006439. Medicare Learning Network website. http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf.

2. National Kidney Disease Education Program. Chronic Kidney Disease and Diet: Assessment, Management, and Treatment. September 2011. NIH Publication No. 11-7406. http://nkdep.nih.gov/resources/ckd-diet-assess-manage-treat-508.pdf.

3. Centers for Medicare & Medicaid Services. CMS Data Compendium: Table VI.13a and Table VI.13b – Medicare Physician and Other Practitioner Registry by Specialty, July 2008. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/DataCompendium/15_2009_Data_Compendium.html.

4. U.S. Renal Data System. USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2010.

5. Narva AS. How to increase early nutrition intervention with CKD Patients: Key insights from a roundtable discussion with renal dietitians. Renal Nutrition Forum 2007; 26:1,3–4

6. Newman EP, Zawislanski A. Addressing the growing need for chronic kidney disease (CKD) medical nutrition therapy in primary care settings: Update on the National Kidney Disease Education Program’s CKD Diet Initiative. Renal Nutrition Forum 2010; 29:8–10.

May 2014 (Vol. 6, Number 5)