Managing Chronic Kidney Disease in Long-term Care
By Janet McKee, MS, RD, LD/N, and
Susan Tassinari, CSG, MS, RD, LD/N
Vol. 9 No. 6 P. 52
Chronic kidney disease (CKD) is a permanent loss of kidney function and is categorized by stages based on glomerular filtration rate (GFR). CKD decreases the kidneys’ ability to perform necessary functions and may eventually lead to kidney failure, requiring dialysis or a transplant to maintain life.
According to the National Kidney Foundation, the incidence of CKD has risen progressively during the past 30 years. Currently, 19.2 million Americans, or 11% of the population, have CKD, and another 20 million are at increased risk. Kidney disease is the ninth leading cause of death in the United States, with more than 80,000 deaths from CKD reported annually.1
Racial and ethnic minorities have a higher risk of CKD, especially African Americans and American Indians.2 In addition, age is a key predictor independent of other risk factors. Eleven percent of the U.S. population aged 65 or older has moderately to severely decreased kidney function.1 The two most common causes of CKD are diabetes and hypertension. Currently, diabetes accounts for nearly one half of all new end-stage renal disease (ESRD) cases.
It is clear from these statistics that many residents of skilled nursing and assisted living facilities are at risk for or have CKD. The number of geriatric ESRD patients in the United States is increasing disproportionately to other age groups on dialysis. As a result, there will be more dialysis patients requiring the assistance of nursing homes in the future. In fact, some facilities in Florida recently reported that more than 5% of their residents receive routine dialysis treatments.
The long-term care dietitian must be familiar with the standards of care for both predialysis CKD and ESRD. Because there is evidence that earlier stages of CKD can be detected and treated and adverse outcomes prevented or delayed, the long-term care dietitian should play an active role in determining which residents are at risk for or have CKD.
Screening and Diagnosis
Determining which long-term care residents are at risk for CKD is fairly simple. Those residents with diabetes and hypertension, particularly minorities, are at highest risk. While not all at-risk residents will have CKD, preventive measures should be followed and include the following:
• stringent control of blood pressure with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers; and
• careful glycemic control in individuals with diabetes.3
It is important to remember that undernutrition is a significant problem in long-term care. The diet must be liberalized to the extent possible while still maintaining good glycemic control. A consistent carbohydrate meal plan has been shown most effective for controlling blood sugars and allowing residents flexibility in meal choices.
To determine which residents at risk for CKD may be in the early stages of the disease, a simple, cost-effective diagnostic tool is needed. The urine albumin test, which detects microalbuminuria, is the most sensitive test for detecting early-stage CKD. Current recommendations call for annual urine testing of all individuals with diabetes.4 There are no recommendations for testing other individuals, but testing for proteinuria with the dipstick method has been shown as cost-effective in individuals with hypertension.
CKD can also be clinically diagnosed by the GFR, which measures the level of kidney function and determines the stage of kidney disease. Normal GFR in both kidneys in adults is 120 to 125 milliliters per minute per 1.73 meters squared. The lower the GFR result, the greater the decline in kidney function. The GFR can be calculated by the laboratory with one of two mathematical formulas:
• The Cockcroft-Gault equation:
GFR = [(140-age) X body weight (kilograms) X 0.85 (if female)]/72 X serum creatinine (milligrams/deciliter); or
• The Modified Diet in Renal Disease equation:
GFR = 170 X [serum creatinine concentration (milligrams/deciliter) -0.999] X [age -0.176 ] X [0.762 (if patient is female)] X [1.18 (if patient is black)] X [serum urea nitrogen concentration (milligrams/deciliter) -0.170 ] X [serum albumin concentration (grams/deciliter) +0.318 ].2
The GFR is used to determine the stage of CKD. Table 1 lists these stages. There is evidence that a low-protein diet can be used to delay the progression of early-stage CKD. When protein is restricted, adequate intake of calories is needed to maintain body weight, protein stores, skin integrity, and overall nutritional health.
Nutritional Management of CKD in Long-term Care
The goals of nutritional management of CKD across the continuum of care include delaying the progression of kidney disease, preserving protein and nutritional status, minimizing complications and symptoms, and maintaining blood chemistries. Nutritional management of residents with CKD, as with all residents, should follow the Nutrition Care Process developed by the American Dietetic Association (ADA).5
The Nutrition Care Process begins with a comprehensive nutritional assessment. The assessment for residents at risk for or with CKD includes an evaluation of the same areas as any other assessments. Anthropometrics, biochemical data, clinical and physical data, and dietary history should all be assessed. Areas of particular importance in long-term care are as follows:
1. Weight history
The dietitian should analyze the resident’s current weight, usual weight, and body mass index to determine whether the resident has had a recent involuntary weight loss or is at risk for malnutrition.
2. Chewing/swallowing ability
The dietitian should observe the resident at mealtime to look for signs and symptoms of difficulty chewing and swallowing and to determine whether the resident is tolerating the diet as ordered. If the resident exhibits chewing or swallowing difficulties, the dietitian should request a consult for the speech therapist. Once evaluated by the speech therapist, a care plan should be developed to ensure that the resident receives the appropriate diet and required supervision with meals.
3. Feeding ability
The dietitian should observe the resident during mealtime to determine whether he or she requires assistance with meals or adaptive devices. If the resident appears to have difficulty eating, the dietitian should request a consult with the occupational therapist. Once evaluated by the occupational therapist, the dietitian should confirm that a care plan is in place to ensure the resident receives adequate assistance or equipment with meals.
4. Diet order
The dietitian should review the diet order to determine whether it can be liberalized for the resident. Liberalized diets help increase intake and prevent malnutrition, but the decision to liberalize the diet must be balanced against the need to restrict protein in early-stage CKD and the need for tight glycemic control.
5. Lab values
A baseline albumin and prealbumin should be recommended so nutritional status can be monitored and changes in protein status evaluated. Both albumin and prealbumin may be affected by stress and infection and must therefore be evaluated in the context of the resident’s current medical status. In addition, prealbumin is elevated in renal disease but is still a valid marker of protein-energy status.
To overcome the limitation of higher prealbumin levels, it is recommended that the outcome goal for prealbumin be greater than or equal to 30 milligrams per deciliter. The dialysis facility draws labs each month. The dietitian should contact the dialysis facility to determine when labs are drawn and arrange a telephone conference with the dialysis dietitian after the labs are received.
6. Fluid restrictions
The new Centers for Medicare & Medicaid Services (CMS) survey guidelines require that staff be aware of fluid restrictions and fluid intake be monitored. The dietitian should review the procedure for providing and monitoring fluids for residents with fluid restrictions. For dialysis residents not on a fluid restriction, the dietitian should consult the dialysis facility to determine whether a fluid restriction is required.
7. Educational needs
The new CMS survey guidelines require that all residents on dialysis understand any dietary restrictions, including food and fluids. The dietitian must evaluate the resident’s current intake, including calories, macronutrients, sodium, potassium, calcium, phosphorus, fluids, vitamins, and minerals to determine the resident’s dietary compliance and need for diet education.
8. Nutrient needs
Nutrient needs in long-term care are the same as those for other individuals with CKD. Calculation of estimated nutrient needs must be balanced with the need for liberalization of the diet. Detailed nutrient requirements can be found in the Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease published by the National Kidney Foundation.6 A summary of nutrient needs specific to long-term care is shown in Table 2.
The next step of the Nutrition Care Process is the nutrition diagnosis, a detailed explanation of which is beyond the scope of this article. Detailed information on the development of the nutrition diagnosis statement can be found in the ADA’s Nutrition Diagnosis and Intervention manual. It is important to note that CKD is a medical diagnosis. The nutrition diagnosis will be a statement of the problems the resident is experiencing due to CKD, such as abnormal labs, excessive weight gain, lack of dietary compliance, or lack of knowledge.
Once the nutrition assessment and diagnosis statement is complete, step three of the Nutrition Care Process, the nutrition interventions, can be planned and implemented. The first component—planning—involves deciding on the interventions that will address the identified problem. Interventions should be based on the current practice standards and developed in coordination with the dialysis facility dietitian.
Interventions specific to long-term care residents include:
Liberalize the diet to the extent possible based on Table 2. Add low concentrated sweets or carbohydrate-controlled restriction for residents with diabetes. Work with the dialysis dietitian to individualize the diet to each resident’s specific needs.
Sack breakfast or lunch
Each patient who receives dialysis treatment outside the facility must be provided with a bag breakfast or lunch depending on the time the resident has dialysis treatment. A sack breakfast and lunch menu cycle must be in place to ensure that consistency and adequate nutrition are provided. Dietary employees must receive training on renal diets and the use of sack breakfast and lunch meals.
Always try a food first by obtaining and honoring the resident’s preferences. If a supplement is necessary, try choosing supplements that are high-calorie and high-protein in a small volume. Monitor the resident’s sodium, potassium, calcium, and phosphorus levels as needed. A method must be developed to ensure supplements are provided with the resident’s sack breakfast or lunch on dialysis days.
Nausea, vomiting, poor intake, loss of appetite
Residents with poor intake or decreased appetite may benefit from a liberalized diet, as previously discussed. Giving small, frequent meals that emphasize the resident’s preferences may also help. Minimizing food odors by using cold protein foods, such as meat sandwiches, can help avoid nausea as can softer, less spicy foods.
Edema, high blood pressure, or excessive weight gain between dialysis treatments
For residents experiencing any of these problems, it may be necessary to limit sodium intake. If a salt restriction is required, the dietitian should explain to the resident the benefits of reducing sodium intake to encourage compliance. Alternative methods for adding flavor to foods should be tried. If weight gains are excessive between treatments, the dietitian should consult with the dialysis dietitian to determine the appropriate fluid restriction and educate the staff on providing and monitoring fluids correctly.
Many long-term residents are capable of understanding their diet. The diet should be explained using survival level terms and handouts. Based on the resident’s diet order, the dietitian should relate the physical effects of diets high in protein, sodium, potassium, phosphorus, calcium, and/or fluids and how limiting these nutrients can help the resident feel better. Diet education should be documented in the resident’s chart, including the education and materials provided and the resident’s comprehension and willingness to comply. Residents who are noncompliant should be reeducated at regular intervals based on labs, weight changes, and other physical effects, and the reeducation should be documented. Caregivers, including staff and family, should be educated when the resident cannot understand the dietary restrictions.
The second component of the intervention step is implementation. This includes the development of a nutrition problem list with an individualized plan of care and prioritized interventions and an individualized diet prescription and meal pattern. The Nutrition Diagnosis Statement and the planned interventions will form the basis of the nutrition care plan. The dietitian and/or the facility staff should follow up on all recommendations and ensure that they are implemented in an expeditious manner.
Once the interventions are implemented, the dietitian and facility staff must monitor the resident’s response and revise the care plan as needed. Consultant dietitians will need to develop a procedure for communicating with the facility between visits as necessary. Communication between the dialysis center dietitian and long-term care dietitian is critical to this step, and documentation of this communication is expected by state and federal surveyors. The long-term care dietitian should speak with the dialysis dietitian on at least a monthly basis. Weight status and changes, labs, fluid gains, skin status, and any other concerns should be reviewed and documented. If the dialysis facility is unable to weigh the resident, the facility must weigh the resident at least once per week following dialysis treatment.
The prevalence of CKD in the elderly population is increasing each year. The long-term care dietitian must be alert to residents at risk for or with early-stage CKD to implement nutrition care plans that ensure maintenance of adequate nutrition status while minimizing complications and symptoms of the disease.
For more information on medical nutrition therapy in CKD, visit www.beckydorner.com, where a prerecorded teleseminar with accompanying CEUs is available.
— Janet McKee, MS, RD, LD/N, is the president and owner of Nutritious Lifestyles, Inc. She is an author, a speaker, and a nutrition expert who has provided nutrition expertise and consultant services to the healthcare and legal industries, the media, the public, dietetics, and the nutrition and foodservice field for more than 25 years.
— Susan Tassinari, CSG, MS, RD, LD/N, is the former vice president of Nutritious Lifestyles, Inc. and is the current president of Medical Nutrition Consulting LLC. She is a practicing consultant in long-term care throughout Florida and provides expert witness services to law firms throughout the United States.
1. Schoolwerth AC, Engelgau MM, Rufo KH, et al. Chronic kidney disease: A public health problem that needs a public health action plan. Prev Chronic Dis. 2006; 3(2):A57.
2. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and Stratification. 2002. Available here. Accessed March 26, 2007.
3. Formica RN. CKD Series: Delaying the Progression of Chronic Kidney Disease. Hospital Physician. 2003;39(4):24-33, 43.
4. Snyder S, Pendergraph B. Detection and evaluation of chronic kidney disease. Am Fam Physician. 2005;72(9):1723-1732.
5. Nutrition Diagnosis and Intervention: Standardized Language for the Nutrition Care Process. Chicago, Ill.: American Dietetic Association; 2007.
6. McCann L (ed). Pocket Guide to Nutrition Assessment of the Patient With Chronic Kidney Disease. New York, N.Y.: National Kidney Foundation; 2002.
American Association of Kidney Patients: www.aakp.org
American Dietetic Association: www.eatright.org
“Current Recommendations for Medical Nutrition Therapy for the Patient with Chronic Kidney Disease” by Janet McKee, MS, RD, LD/N, and Susan Tassinari, CSG, MS, RD, LD/N. Prerecorded teleseminar available at www.beckydorner.com.
The Florida Medical Nutrition Therapy Manual, 2005 Edition
National Institutes of Diabetes & Digestive & Kidney Diseases: www2.niddk.nih.gov
National Kidney Foundation (NKF): www.kidney.org
The Nephron Information Center: http://nephron.com
NKF K/DOQI Guidelines: kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
Worldwide Kidney Disease Community: http://ikidney.com
© 2007 Becky Dorner & Associates, Inc. Visit www.BeckyDorner.com for free articles, information, publications, CEU programs and teleseminars, and to sign up for our free monthly email magazine. 1-800-342-0285.