Optimal nutrition has a profound impact on kidney health and survival. CKD-related nutritional disorders extend from overnutrition to undernutrition to more extreme disorders of protein-energy wasting and cachexia. Effective nutritional care has the potential to not only slow progression of CKD but also improve metabolic control, hypertension, quality of life, mortality, and the gut microbiome.
The landscape of kidney nutrition is evolving. From emphasis on kidney restrictive diets, the focus is shifting toward understanding the potential roles of plant-based diets, probiotics, bioavailability of nutrients and micronutrients, modulation of the gut microbiota, precision nutrition, and dietary liberalization. Moreover, the coronavirus disease 2019 pandemic has emphasized the benefits of kidney telenutrition. These opportunities are here to stay. A prudent approach to strengthen the nutrition care process globally is critical. Key ingredients for effective kidney nutrition care include equitable access to dietitians, resources, empowerment of nutrition professionals, sociocultural considerations, interdisciplinary shared decision making, patient-centered goals and outcomes, and cost-effectiveness.
In this issue of CJASN, the International Society of Nephrology and the International Society of Renal Nutrition and Metabolism joined hands to assess the global status of kidney nutrition care. A multinational cross-sectional Global Kidney Nutrition Care Survey, conducted with the International Society of Nephrology Global Kidney Health Atlas project, obtained responses on kidney nutrition care from 22 low-income countries (LICs), 35 lower middle–income countries (LMICs), 41 upper middle–income countries (UMICs), and 57 high-income countries (HICs) (1). Three key stakeholders (society leader, policy maker, and consumer organization representative) from each country were invited to participate. Nephrologists constituted the majority of respondents (71%–85%), with policy makers or nonphysician health professionals constituting <6% across countries.
The survey focused on the availability of dietitians/kidney nutrition care services, costs, and interdisciplinary communication.
Over half of respondent countries (52%) did not have dietitians for kidney nutrition care, with unequal global distribution. Dietitians were available in 77% of HICs, 20% of LMICs, and 9% of LICs. Access to dietitians was better for inpatients and patients on dialysis, in some countries necessitating out-of-pocket expenditure. Personnel other than dietitians provided dietary counseling in 85% countries (86% in HICs, 94% in LMICs, and 73% in LICs). Although availability of trained dietitians and dietary counseling services were high in HICs, nephrologists provided dietary counseling in 51%. Dietitians always provided formal feedback on nutritional assessment to nephrologists in under 25% of HICs and even less elsewhere. Moreover, dietitians always provided feedback on dietary prescription to nephrologists in only 7% of HICs and 14% in LMICs. Among LMICs/LICs, nephrologists and non-nephrologist physicians primarily delivered dietary counseling. Formal assessment of nutritional status was undertaken in only 54% of countries, with common tools such as body weight, serum albumin, and body mass index. Oral nutritional supplements (oral meal supplements/vitamins) were available in 81% of countries, but related costs were covered in only 25%–52%. Across LICs, formal assessment of nutritional status was undertaken in under 20%, despite availability of assessment tools (59%–68%) and oral supplements (64%).
A major strength of this survey is its global reach and the comprehensiveness of the aspects of kidney nutrition covered. An important limitation, however, is that most respondents were nephrologists; therefore, other stakeholder perspectives may not be fully recognized. Nonetheless, this survey provides important observations. Gaps in awareness, implementation, and integration of the nutrition care process exist globally, and access to trained personnel and capacity building remain major challenges for low-resource countries. A diverse approach to addressing challenges specific to the spectrum of income group countries is needed to improve insights for policy making and action. Reinforcement of the nutrition care process for patients and families, regional diet adaptation strategies, and sharing of kidney nutrition care protocols and training tools between regions are critical.
Strategic plans to enhance workforce capacity worldwide toward integrated kidney failure care have been outlined (2). This issue is not limited to low-resource countries. A recent cross-sectional study undertaken by the National Kidney Foundation revealed poor access to registered dietitians in patients with CKD stages 1–5 (3). A critical barrier was the lack of renal dietitians. In the absence of dietitians—more commonly observed in LMICs/LICs—clinicians, nurses, technicians, and primary care physicians should be offered nutrition-specific training. Learning modules applicable to low-resource settings on peritoneal dialysis skills and conservative management of AKI are available from the ISN Academy (https://academy.theisn.org). Similarly, LMICs/LICs should improve opportunities for skill-based training for nephrologists, nurses, and dietitians in kidney nutrition care. Setting up national societies for renal nutrition and integration with dietetic societies and nephrology forums can strengthen the workforce. Online certificate programs on CKD nutrition management and standards for professional performance for registered dietitians are in place (4,5). A North American nutrition survey revealed that over half of the adult-focused renal dietitians spend some time with pediatric care; therefore, more pediatric-focused educational materials are needed (6). Pediatric nephrologists providing kidney nutrition care to children and adolescents are challenged with the specific issues of optimizing growth and fluid intake while restricting certain nutrients, achieving adequate nutrition for infants on dialysis, and nutrition-related issues associated with transition from adolescent to adult care.
A feasible training option that works well in low-resource settings is the train-the-trainer (ToT) model. This model (Figure 1) builds a pool of competent instructors and facilitators who can disseminate knowledge and skills to many more health care professionals. In the context of building a dedicated workforce for kidney nutrition, the ToT approach offers the opportunity to improve interdisciplinary communication and care process implementation.
As highlighted in the global survey (1), providing cost-effective nutritional consultation and supplements is a challenge (3). In a qualitative study from Kenya, patients struggled to procure prescribed locally available foods and undertook uninformed dietary decisions, leading to consumption of unhealthy foods (7). Financial security and provision of culturally appropriate foods are essential everywhere, and are especially relevant in low-resource settings. Many of the formula foods and commercial supplements recommended by HICs are not available or affordable in LMICs and LICs. In such situations, dietary prescriptions are limited to home-based foods/supplements in general, with use of milk protein–based malnutrition formula feeds in selected children.
Challenges relating to access and delivery of optimal nutrition care are not limited to low-resource countries. A qualitative study from a HIC explored the experiences of renal dietitians in providing nutritional support to adults with kidney failure. Apart from time constraints, dietitians perceived challenges due to conflicting inputs from other health care professionals, as well as concerns regarding nutrition-specific knowledge of nurses and doctors regarding CKD (8). Low utilization of the nutrition care process in CKD, workforce considerations, optimal time and periodicity of nutrition care, assessment of staffing, and staff burnout are additional important issues (9).
In this panorama of kidney nutrition care, what should be the next steps to address the conundrum and gaps across the spectrum of income-group countries? How could regional bodies support and escalate the nutrition care process? Are guidelines and clinical practice recommendations being translated at the bedside? Should emphasis be placed only on education or also on kidney nutrition–related research in LMICs/LICs?
Access to optimal nutrition is also highly relevant to meeting 12 of the sustainable developmental goals for 2030 and for prevention of kidney disease (10). Further, emphasis should be placed on access to healthy and safe food amid existing poverty, not forgetting vulnerable populations everywhere, where “food deserts” exist in the midst of plenty. This global survey is an important wakeup call to countries across the income spectrum. It exposes gaps and concerns related to kidney nutrition care, serving up a plate full of food for thought that must now be followed by action.
A. Iyengar reports serving as a member of the Editorial Board for Frontiers in Pediatrics and Peritoneal Dialysis International; as Chair of the Clinical Research Program of the International Society of Nephrology 2021–2023; and as a member of the IPNA, IPTA, ISN, ISRNM, TTS, and WIN. V.A. Luyckx reports receiving honoraria as an invited speaker at the German Nephrology Meeting and as speaker in Grand Rounds University of Miami, Brigham and Women’s Hospital, with no pharmaceutical connections; serving on the Editorial Boards of CJASN, Current Opinion in Nephrology, Kidney360, and Nature Reviews Nephrology; and receiving royalties from Elsevier as editor of the textbook The Kidney.
Dr. A. Iyengar acknowledges her PhD team and the Division of Nutrition at St John's Research Institute, St John's National Academy of Health Sciences, Bangalore. The content of this article reflects the personal experience and views of the author(s) and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or CJASN. Responsibility for the information and views expressed herein lies entirely with the author(s).
1. Wang AY-M, Okpechi IG, Ye F, Kovesdy CP, Brunori G, Burrowes JD, Campbell K, Damster S, Fouque D, Friedman AN, Garibotto G, Guebre-Egziabher F, Harris D, Iseki K, Jha V, Jindal K, Kalantar-Zadeh K, Kistler B, Kopple JD, Kuhlmann M, Lunney M, Mafra D, Malik C, Moore LW, Price SR, Steiber A, Wanner C, ter Wee P, Levin A, Johnson DW, Bello AK: Assessing global kidney nutrition care. Clin J Am Soc Nephrol 17: 38–52, 2022
2. Harris DCH, Davies SJ, Finkelstein FO, Jha V, Donner JA, Abraham G, Bello AK, Caskey FJ, Garcia GG, Harden P, Hemmelgarn B, Johnson DW, Levin NW, Luyckx VA, Martin DE, McCulloch MI, Moosa MR, O’Connell PJ, Okpechi IG, Pecoits Filho R, Shah KD, Sola L, Swanepoel C, Tonelli M, Twahir A, van Biesen W, Varghese C, Yang CW, Zuniga C; Working Groups of the International Society of Nephrology’s 2nd Global Kidney Health Summit: Increasing access to integrated ESKD care as part of universal health coverage. Kidney Int 95[Supp 4]: S1–S33, 2019
3. Jimenez EY, Kelley K, Schofield M, Brommage D, Steiber A, Abram JK, Kramer H: Medical nutrition therapy access in CKD: A cross-sectional survey of patients and providers. Kidney Med 3: 31–41.e1, 2020
4. National Institute of Diabetes and Digestive and Kidney Diseases, Chronic Kidney Disease Nutrition Management Training Program. Available at: https://www.niddk.nih.gov/health-information/professionals/education-cme/management-training-program
. Accessed December 13, 2021
5. Pace RC, Kirk J: Academy of Nutrition and Dietetics and National Kidney Foundation: Revised 2020 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nephrology nutrition. J Ren Nutr 31: 100–115.e41, 2021
6. Nelms CL, Johnson E, Peseski S: Determination of renal nutrition training and education need for pediatric-focused and adult-focused clinicians: The North American Pediatric Renal Nutrition Education Survey (NAPRNES). J Ren Nutr 29: 91–96, 2019
7. Okoyo Opiyo R, Nyawade SA, McCaul M, Nyasulu PS, Lango DB, Were AJO, Nabakwe EC, Bukania ZN, Olenja JM: Perceptions on adherence to dietary prescriptions for adults with chronic kidney disease on hemodialysis: A qualitative study. Diseases 8: 29, 2020
8. Lambert K, Mansfield K, Mullan J: Qualitative exploration of the experiences of renal dietitians and how they help patients with end stage kidney disease to understand the renal diet. Nutr Diet 76: 126–134, 2019
9. Hand RK: Workforce needs and estimated costs/savings for nutrition care in chronic kidney disease-stage 3 through maintenance dialysis [published online ahead of print August 10, 2021]. Semin Dial
10. Luyckx VA, Al-Aly Z, Bello AK, Bellorin-Font E, Carlini RG, Fabian J, Garcia-Garcia G, Iyengar A, Sekkarie M, van Biesen W, Ulasi I, Yeates K, Stanifer J: Sustainable development goals relevant to kidney health: An update on progress. Nat Rev Nephrol 17: 15–32, 2021