If you are a new renal dietitian, it didn’t take long to discover you are working with a patient population that has multiple, sometimes complex nutritional needs. Where do you turn for help in making sure your recommendations and interventions are appropriate and credible with other members of the health care team?
Clinical practice guidelines
Evidenced-based practice guidelines are developed by expert teams using a systematic process of identifying, analyzing and synthesizing peer-reviewed scientific studies published in the medical literature. In many instances there may be insufficient evidence to address a particular issue; in such cases, the leaders in that field reach a consensus on best practice recommendations.
It is important to remember that any practice guideline is just that – a guide or starting point for clinical decisions. They are not intended to be used as rules or regulations in place of sound clinical judgment. And, updating practice guidelines can be challenging. It is important to know the dates and timing related to publication of guidelines because any new findings or breakthroughs may not have been included.
In 2000, the Clinical Practice Guidelines for Nutrition in Chronic Renal Failure were published by the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI). These guidelines include 22 adult and 10 pediatric recommendations, information on the development process, rationale for the recommendations, suggestions for future research and appendices filled with charts and methods for nutritional assessment of dialysis and advanced chronic renal failure.
Developing clinical practice guidelines takes an immense amount of time and effort on the part of numerous professionals. The interdisciplinary workgroup for the nutrition guidelines was first assembled in 1997 to review key nutrition literature and to define specific topics the guidelines would focus on. From the starting point of 24,487 titles identified in the first literature search (1966 through 1997) 22,362 titles were rejected for not meeting specific criteria. The review process continued into the next year with the work group evaluating abstracts and developing evidence tables, leaving them 250 acceptable articles by October 1998. Guidelines were formulated and supporting rationale for each guideline was drafted and the first draft was ready for the NKF Steering Committee’s review by August 1999. By December, the second draft of the guidelines was submitted for review to individuals representing nearly 50 renal organizations and nephrology professional societies. By late December the document went through “open review” with comments coming from interested individuals in the renal community. After additional editing for clarity and consistency, the guidelines were ready for publication and appeared as a supplement to the American Journal of Kidney Diseases in June 2000.
KDOQI continued to develop guidelines for other clinical conditions such as diabetes, hypertension, anemia, lipids, and mineral and bone disorder with relevant nutritional issues included. They have continued to re-evaluate and update previously published guidelines as new evidence warrants a review. Guidelines for kidney disease have expanded to include international experts with the initiative Kidney Disease: Improving Global Outcomes(KDIGO).
Other professional organizations have developed nutrition practice guidelines that can also serve as a resource. Chronic Kidney Disease Nutrition Practice Guidelines can be found in the Evidence Analysis Library of the Academy of Nutrition and Dietetics and while not specific to kidney disease, nutrition practice guidelines for diabetes are helpful for clinical decision making and problem solving with this common comorbidity in the CKD population.
Sources for helpful guidelines for the renal dietitian
The following list of guidelines will give the new dietitian in renal care a starting point for determining best practice, but are not meant to replace professional judgment.
KDIGO Clinical Practice Guidelines http://kdigo.org/home/guidelines/
- Acute kidney injury
- Anemia in chronic kidney disease
- Care of kidney transplant recipients
- Diagnosis, evaluation, prevention and treatment of chronic kidney disease related mineral and bone disorders (CKD_MBD)
- Prevention, diagnosis, evaluation and treatment of Hepatitis C in chronic kidney disease
KDOQI Clinical Practice Guidelines (National Kidney Foundation) www.kidney.org/professionals/KDOQI/guidelines_commentaries.cfm
- Diabetes and chronic kidney disease
- Chronic kidney disease: Evaluation, classification, and stratification
- Hypertension and antihypertensive agents in chronic kidney disease
- Managing dyslipidemia in chronic kidney disease
- Nutrition in chronic renal failure
- Hemodialysis adequacy
- Peritoneal dialysis adequacy
- Cardiovascular disease in dialysis patients
- Nutrition therapy recommendations for the management of adults with diabetes Diabetes Care, vol. 37, Supplement 1, January 2014. S120-143
- Chronic kidney disease nutrition practice guidelines (Academy of Nutrition and Dietetics) www.eatright.org/evidenceanalysislibrary
- Pocket guide to nutrition assessment of the patient with chronic kidney disease 4th edition. Council on Renal Nutrition of the National Kidney Foundation.