The Renal Dietitian's Role in the Treatment of Kidney Disease.

The Key Role of the Renal Dietitian and the Importance of Nutrition

The management of chronic illness is often designed to prolong life while maintaining or improving its quality. Unfortunately, treatments for chronic disease may force people to make significant changes in their lives. Their activities may be restricted and their diets may be modified. They may need medical equipment to sustain life. Frequent clinic or doctor visits and multiple hospitalizations are common. People with kidney failure face most or all of these challenges on an ongoing basis. These articles review the details of a nutritional evaluation and the theoretical underpinnings of a dietary approach to the treatment of kidney disease. The renal dietitian is an important member of the healthcare team that manages kidney disease. The renal dietitian interacts with and educates people with kidney failure, and their family members and/or caregivers. Their job of identifying and managing nutritional problems involves a careful balance of the nutrient composition of the diet, making modifications in consultation with the physician, and should also take the cultural traditions of the person using the diet into

consideration.

Good nutrition is important in the management and treatment of diseases. Kidney disease is no exception. Several studies have documented that people who have kidney disease benefit from adequate nutrition.

The kidneys are an important organ in the body. They are responsible for filtering blood, and removing waste products and extra fluid from the body through the urine, to prevent a build-up that could poison the body. The kidneys are also important in maintaining salt and water balance, and for producing substances that regulate blood pressure, maintaining healthy bones, and preventing anemia. Many things may cause kidney failure, including chronic diseases, genetic abnormalities, or trauma. When someone has kidney failure, waste products are not removed from his or her body as they should be.

The renal dietitian's background and training

Renal dietitians are experts on diet and nutrition in kidney disease. The majority of renal dietitians in the United States are registered dietitians (RD). The letters "RD" after a person's name signifies that he or she is a registered dietitian who has completed academic and practical experience requirements in nutrition and dietetics, and has passed a registration examination established by the Commission on Dietetic Registration of the American Dietetic Association.

Registered dietitians are trained and educated extensively in the science of nutrition and its application to disease prevention and treatment. They integrate and apply the principles of nutrition science, biochemistry, physiology, food management, and behavior to achieve and maintain health, and to prevent disease.

Renal dietitians have extensive training in identifying and managing the nutritional problems of people who have kidney disease. An individual who has kidney disease, whether chronic kidney failure or end stage kidney disease (more commonly referred to as end stage renal disease, or ESRD), should be referred by a physician to a renal dietitian for nutrition consultation at the first signs of kidney failure.

The renal dietitian will perform a complete nutrition assessment that includes: a review of the individual's medical, surgical, and diet histories, blood tests, and medications. The dietitian may also complete a nutrition physical assessment. Each component of the nutrition assessment provides the dietitian with important information. Blood tests are used to assess nutritional status and evaluate the degree of kidney failure. A review of medications may indicate potential drug/nutrient interactions that affect nutritional status. The diet history provides information about eating patterns, cultural and religious food practices, and food likes and dislikes. Medical and surgical histories provide the dietitian with information about other medical problems that may affect nutritional status.

After the information is collected and reviewed, the dietitian develops a nutritional care plan with objectives and goals. The care plan includes nutrient requirements, such as the amount of protein and calories that the person needs to maintain a good nutritional status. The dietitian also incorporates information obtained from the nutritional assessment with the diet prescription from the doctor to develop an individualized meal plan. Follow-up nutrition counseling is scheduled on a continuing basis depending on the degree of kidney failure. It is important that the person who does the food shopping and cooking for the household take part in the nutrition counseling sessions.

The renal dietitian's role on the renal team

The person with ESRD who requires dialysis receives their medical care from the healthcare team at the dialysis center. The team is a group of trained professionals and specialists that includes the doctor, nurse, dietitian, social worker, and dialysis technician who work together to provide the best possible care for the most important member of the healthcare team: the person who has kidney failure.

In most dialysis units, the dietitian completes a nutritional assessment during the first month of dialysis and, thereafter, on a monthly or quarterly basis. The dietitian also provides on-going nutritional counseling which includes a review of the monthly blood work and an evaluation of dietary compliance and dialysis adequacy. Family members and/or caregivers are encouraged to be part of this ongoing counseling.

Changing your diet

Dietary compliance can be a major problem because most people with kidney disease have to make adjustments in their usual diet. These modifications are based on the degree of kidney failure (chronic or end stage) and the type of treatment being used (hemodialysis or peritoneal dialysis). Modifications may include changes in the nutrient composition of the diet such as protein, calories, potassium, sodium, phosphorus, and fluid. Dietary modifications will change as the kidney function changes, and the dietitian, in consultation with the doctor, will recommend changes in the diet prescription accordingly. The renal dietitian provides instruction on planning nutritious meals and selecting the right kinds of foods to decrease the production of waste products. The primary goal is to optimize remaining kidney function or to complement the dialysis treatments.

The ability to incorporate cultural foods, practices, and preferences in the dietary plan is important for dietary compliance. Cultural awareness is essential for effective nutrition counseling. The dietitian must be familiar with the social context of food habits, beliefs, and practices of the individual before counseling begins. Some dietitians have to educate people from all areas of the world who have various cultural and religious food practices. This is especially true during specific holidays when traditional foods are prepared and eaten, sometimes regardless of the diet plan.

Eating is also a social activity that is influenced by culture. Cultural food habits and practices may also be modified by contact with other cultures, urbanization, changes in living conditions, work schedules, availability of traditional foods, income and education level, and interest and motivation in changing established food patterns. If a dietitian is not aware of cultural differences, he or she may educate patients on how to eat the typical American diet without consideration for cultural habits. When the dietitian is aware of cultural differences in eating, he or she can teach people how to make good choices using foods they commonly eat and enjoy, and to incorporate these foods into the individualized meal plan.

Whatever the belief and practice, every diet plan needs to be individualized for the person who must follow it.

Conclusion

The registered dietitian is the source [or reliable, up-to-date food and nutrition information. The renal dietitian plays a major role in the nutritional care of individuals who have kidney disease. The primary goal of maintaining a good nutritional status is usually accomplished with an early referral to a renal dietitian, an adequate food intake, and compliance with the diet prescription and meal plan. If you or someone you know has kidney disease, seek the advice of a renal dietitian.

Suggestions

* Review menus from your favorite restaurants and fast food chains with your renal dietitian who will help you plan meals.

* Provide your renal dietitian with recipes of your favorite foods or traditional holiday dishes for incorporation into the meal plan.

* Learn to read food labels for nutrient content.

* Attend workshops or conferences for people who have kidney disease.

RELATED ARTICLE: Nutrition made the difference

by Kathleen Jacobs

My son, Christian Jacobs, was born without one kidney and ureter. The other kidney was small and damaged. He had vesicoureteral reflux (fluid backup) from the bladder that caused further damage to the kidneys. He also had severe gastroesophageal reflux that caused vomiting, dry heaves, weight loss, and failure to thrive.

When Christian was 6 weeks old, the doctors told us that he was probably as healthy as he would ever be. They could not tell us what his life expectancy would be. We were given little hope and few answers.

Christian is now almost 10 years old. He has had five major surgeries for various problems, including vomiting and gagging. He does not enjoy eating, so he has a feeding tube to help him gain weight. He is nauseated most of the time. We tube feed him every morning to try to increase his weight. He is doing very well. Although Christian is in end stage renal disease, we have chosen not to use dialysis at this time because it would be too disruptive to his childhood. We are managing his disease with the help of a renal team. The nephrologist draws blood to monitor his status every month, and we consult with a renal dietitian every three to six months.

Christian takes 12 medications daily and receives injections to help his severe anemia. He has to be catheterized every three hours to drain the extra fluid from his system to reduce urinary tract infections. This is important for him to be considered for a transplant. Christian is on a waiting list to receive a donor kidney, and we carry a beeper with us everywhere we go, hoping for the phone call telling us that one is available for him.

The doctors are amazed at how well Christian looks and functions. We believe that the nutritional care Christian has received, including feeding therapy and the feeding tube, has helped him stay as healthy as he is. We wanted him to have a happy, normal childhood, so we never told people about his illness. Until recently, most of his friends and classmates did not know how much Christian has gone through, and continues to go through, to be a "normal kid"; and how much courage it takes for him to get up every day and do what he has to do. When you look at Christian, you see a happy, healthy boy. We think he is a miracle child.

Jerrilynn D. Burrowes, MS, RD, CDN, CDN, is the Research Coordinator for the Division of Nephrology and Hypertension at the Beth, Israel Medical Center in New York City. She serves on the Editorial Board for the Journal of Renal Nutrition and is a member of the National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI).