Assessing Global Kidney Nutrition Care : Clinical Journal of the American Society of Nephrology

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Original Article: Chronic Kidney Disease

Assessing Global Kidney Nutrition Care

Wang, Angela Yee-Moon1; Okpechi, Ikechi G.2,3; Ye, Feng4; Kovesdy, Csaba P.5; Brunori, Giuliano6; Burrowes, Jerrilynn D.7; Campbell, Katrina8; Damster, Sandrine9; Fouque, Denis10; Friedman, Allon N.11; Garibotto, Giacomo12; Guebre-Egziabher, Fitsum13,14; Harris, David15; Iseki, Kunitoshi16; Jha, Vivekanand17,18,19; Jindal, Kailash4; Kalantar-Zadeh, Kamyar20; Kistler, Brandon21; Kopple, Joel D.22; Kuhlmann, Martin23; Lunney, Meaghan24; Mafra, Denise25; Malik, Charu9; Moore, Linda W.26; Price, S. Russ27; Steiber, Alison28; Wanner, Christoph29; ter Wee, Pieter30; Levin, Adeera31; Johnson, David W.32,33,34; Bello, Aminu K.4

Author Information
CJASN 17(1):p 38-52, January 2022. | DOI: 10.2215/CJN.07800621

Abstract

Introduction

It was estimated that >850 million adults have some form of kidney disease worldwide (1). The estimated age-standardized global prevalence of CKD was 10% in men and 12% in women, on the basis of 33 studies between 2006 and 2013 (2). There is a growing number of patients with kidney failure worldwide, representing a huge global health challenge (3). Over 2 million people with kidney failure were estimated to receive KRT worldwide in 2010, and this number is projected to increase to >5 million by 2030 (4). KRT and its complications are costly and unaffordable for many individuals and governments in emerging countries (4567–8).

Nutrition intervention is an important component of CKD management that aims to improve clinical outcomes, optimize quality of life, and enable patients to continue participation and achieve life goals. Nutrition intervention can slow the progression of CKD and delay the need of initiation of KRT (9). It aims to promote a healthy lifestyle and dietary pattern and ameliorate various kidney and cardiovascular risk factors. It serves to optimize the nutritional status of patients with CKD/kidney failure, prevent protein-energy wasting, provide early intervention for those complicated with protein-energy wasting, and allow better symptom control in those who opt for conservative kidney care (Table 1) (10,11). Successful implementation of nutrition interventions requires renal dietitians to deliver regular dietary counseling and monitoring to educate patients and ensure continued adherence to nutrition interventions (12,13). On the other hand, protein-energy wasting is a common complication across the spectrum of CKD and in kidney failure (14) and is associated with adverse clinical outcomes in patients on long-term dialysis (15,16). Oral nutrition supplements, including vitamins and minerals, and liquid nutrition supplements are important interventions for patients with CKD/kidney failure complicated by protein-energy wasting whose dietary intake fails to meet nutritional needs (17,18). Nutrition supplementation has been shown to improve energy and protein homeostasis in patients on long-term dialysis (1920–21) and, in one study, reduced hospitalization (22). However, the global availability and accessibility of nutrition supplements for patients with CKD/kidney failure, especially in economically constrained countries, is unknown.

Table 1. - Potential values of nutrition intervention in patients with CKD and those on long-term dialysis
Potential Values
Kidney specific
 Retard CKD progression and delay need for KRT
 Preserve residual kidney function in people receiving dialysis
 Prolong kidney survival in people who decide on conservative kidney care or have no access to long-term dialysis
Nutrition
 Optimize nutrition status and prevent or ameliorate protein-energy wasting
Metabolic
 Reduce generation of uremic toxins
 Reduce salt loading and improve volume management
 Improve CKD–mineral bone axis parameters
 Improve lipid parameters
 Improve insulin sensitivity
 Improve glycemic control in people with diabetes
 Improve hyperuricemia
 Minimize metabolic acidosis
 Improve weight management in patients who are obese/overweight
Cardiovascular
 Ameliorate various cardiovascular risk factors, including hypertension, diabetes, and dyslipidemia, and improve cardiovascular health
Quality of life and symptom management
 Better CKD symptom management, including in those on conservative kidney care
 Improve quality of life
 Enable greater life participation

The International Society of Renal Nutrition and Metabolism (ISRNM), working in partnership with the International Society of Nephrology (ISN) Global Kidney Health Atlas (GKHA) cochairs, developed a questionnaire for a Global Kidney Nutrition Care Atlas in 2018. The Atlas covers key aspects of kidney nutrition care including (1) current global availability, capacity, and cost of kidney nutrition care services; (2) formal communication between dietitians and nephrologists in the delivery of kidney nutrition care; and (3) worldwide clinical practice patterns in kidney nutrition care delivery. The current publication focuses on the first two aspects. With better understanding of current availability and capacity of global kidney nutrition care services, we hope to define service gaps and needs along with the challenges in meeting global needs. The findings of this survey form an important basis to identify future opportunities to improve global kidney nutrition care.

Materials and Methods

Study Design and Participants

The ISN GKHA project was a multinational, cross-sectional survey conducted by the ISN to assess current capacity for kidney care across the globe (23,24). The survey was administered electronically to individuals in 182 countries with ISN-affiliated societies through the ten ISN regional boards of Africa, Central and Eastern Europe, Latin America, Middle East, North America, North and East Asia, Oceania and Southeast Asia, newly independent states and Russia, South Asia, and Western Europe.

The project was approved by the University of Alberta Research Ethics Committee (protocol number PROOOO63121). All individual participants provided written informed consent. Patients or members of the public were not involved in the design, conduct, reporting, or dissemination plans of this research. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

The GKHA project was supported by the ISN (grant RES0033080 to the University of Alberta). The ISN provided administrative support for the design and implementation of the study and data collection activities. The Global Kidney Nutrition Care Atlas was supported by the ISRNM.

ISN GKHA Methods

As described elsewhere (7,23,24), the ISN GKHA is a project of the ISN aimed at improving the global capacity for kidney care and is involved in conducting an international survey of key stakeholders. We developed the survey in alignment with the World Health Organization’s framework on monitoring health systems (25). Details on the survey development and validation have previously been published (23,24). To date, two iterations of the survey have been conducted (2016 and 2018) (26). We used the 2018 version to survey items specific to kidney nutrition care. The Global Kidney Nutrition Care Survey of the ISN GKHA was designed to collect information concerning current service capacity, availability, accessibility, and cost in relation to monitoring and management of kidney nutrition in patients with nondialysis CKD and patients with CKD on long-term dialysis throughout the world. The questionnaire was developed by the ISRNM and reviewed by its executive committee and council members, the ISN GKHA Steering Committee, and ISN regional leaders for content validity and comprehensiveness. The format and layout of the questionnaire was finalized by the ISN GKHA Steering Committee. Supplemental Appendix 1 provides the questionnaire specific for this Global Kidney Nutrition Care Atlas report.

We purposively sampled three key stakeholders from each of the 182 countries who were identified as having comprehensive knowledge of kidney care in their country—nephrology leader (typically nephrology society president), policy maker, and consumer organization/representative—to participate in the survey on the basis of their knowledge of kidney care and ability to accurately represent their country. These individuals were sourced with the assistance of ISN regional board leaders who identified people with the requisite expertise. Often, but not always, the stakeholders were nephrologists. We administered the survey online via REDCap Cloud (www.redcapcloud.com) from July to September 2018. We stored data in a centralized database and checked for inconsistencies within country responses. We asked ISN regional leaders to clarify discrepancies and subsequently updated the database.

Statistical Analysis

We analyzed data using descriptive statistics and reported findings as an overall aggregate score, stratified by ISN region (27) and by World Bank income group. Country was the unit of analysis. We analyzed data using Stata Statistical Software, release 15 (StataCorp LLC, College Station, TX).

Results

Response Rate

Of the 182 countries that received an invitation to participate in the 2018 survey, 160 (88%) responded. Of the 182 invited countries, 155 (85%) answered the survey items related to kidney nutrition care (Table 2). Supplemental Table 1 provides detailed response rates to individual nutrition questions.

Table 2. - Total number of countries and populations in different ISN regions and World Bank income groups that received and completed the nutrition survey, and the number and nature of nutrition survey respondents
Location Total Countries that Received the Survey, n Total Population of Countries that Received the Survey, millions Total Countries that Completed the Nutrition Q, n Total Population of Countries that Completed the Nutrition Q, millions Total Personnel who Responded to the Q, n Nephrologists who Responded to the Q, n (%) Non-nephrologists (Physicians) who Responded to the Q, n (%) Health Professionals (Nonphysicians) who Responded to the Q, n (%) Administrators/ Policy Makers/ Civil Servants who Responded to the Q, n (%) Others who Responded to the Q, n (%)
Overall 182 7442 155 7246 312 257 (82) 22 (7) 6 (2) 16 (5) 11 (4)
ISN regions
 Africa 46 1246 41 1201 62 48 (77) 8 (13) 2 (3) 2 (3) 2 (3)
 Eastern and Central Europe 20 210 19 209 36 32 (89) 1 (3) 0 (0) 2 (6) 1 (3)
 Latin America and the Caribbean 28 631 18 592 39 33 (85) 3 (8) 0 (0) 2 (5) 1 (3)
 Middle East 13 244 11 214 29 26 (90) 1 (3) 1 (3) 1 (3) 0 (0)
 NIS and Russia 10 277 7 197 11 9 (82) 0 (0) 1 (9) 1 (9) 0 (0)
 North America 13 370 9 370 16 11 (69) 3 (19) 0 (0) 0 (0) 2 (13)
 North and East Asia 7 1597 7 1597 21 20 (95) 1 (5) 0 (0) 0 (0) 0 (0)
 Oceania and Southeast Asia 16 681 15 681 36 29 (81) 1 (3) 1 (3) 2 (6) 3 (8)
 South Asia 7 1752 7 1752 16 11 (69) 3 (19) 0 (0) 2 (13) 0 (0)
 Western Europe 22 433 21 433 46 38 (83) 1 (2) 1 (2) 4 (9) 2 (4)
World Bank groups
 Low income 26 618 22 573 34 24 (71) 8 (24) 1 (3) 1 (3) 0 (0)
 Lower-middle income 42 2986 35 2862 72 60 (83) 3 (4) 3 (4) 3 (4) 3 (4)
 Upper-middle income 48 2593 41 2569 82 70 (85) 5 (6) 0 (0) 5 (6) 2 (2)
 High income 66 1245 57 1242 124 103 (83) 6 (5) 2 (2) 7 (6) 6 (5)
ISN, International Society of Nephrology; Q, questionnaire; NIS, Newly independent States.

Capacity and Availability of Kidney Nutrition Care Services

Availability of Dietitians/Renal Dietitians.

Globally, 48% (75 of 155) of the countries surveyed have dietitians/renal dietitians to provide kidney nutrition care. Dietitians/renal dietitians were more available in countries with higher income levels; only 9% (two of 22) of low-income countries and 20% (seven of 35) of lower middle–income countries had dietitians/renal dietitians, in contrast to 54% (22 of 41) of upper middle–income and 77% (44 of 57) of high-income countries (Figure 1A).

figure2-a
Figure 1-A.:
Global availability and capacity of kidney nutrition care. (A) Availability of dietitians/renal dietitians for different International Society of Nephrology regions and World Bank income groups. (B) Availability of dietary counseling by a person trained in nutrition (either persons with dietetics or nutrition background, nutritionists, nutrition technicians, or physicians, not necessarily nephrologists who have received training in nutrition) for different World Bank income groups. (C) Dietitians/renal dietitians practice settings in outpatient and inpatient settings and nutrition care availability for patients with nondialysis CKD versus those on maintenance dialysis for different World Bank income groups. (D) Personnel who provide dietitian counseling to patients with CKD and personnel other than dietitians involved in kidney nutrition care for different World Bank income groups. C, Central; E, Eastern/East; N, North; NIS, newly independent states; OSEA, Oceania and Southeast Asia.
figure2-b
Figure 1-B.:
Global availability and capacity of kidney nutrition care. (A) Availability of dietitians/renal dietitians for different International Society of Nephrology regions and World Bank income groups. (B) Availability of dietary counseling by a person trained in nutrition (either persons with dietetics or nutrition background, nutritionists, nutrition technicians, or physicians, not necessarily nephrologists who have received training in nutrition) for different World Bank income groups. (C) Dietitians/renal dietitians practice settings in outpatient and inpatient settings and nutrition care availability for patients with nondialysis CKD versus those on maintenance dialysis for different World Bank income groups. (D) Personnel who provide dietitian counseling to patients with CKD and personnel other than dietitians involved in kidney nutrition care for different World Bank income groups. C, Central; E, Eastern/East; N, North; NIS, newly independent states; OSEA, Oceania and Southeast Asia.

Availability of Dietary Counseling by a Person Trained in Nutrition.

Dietary counseling by a person trained in nutrition was generally available in 84% (48 of 57) and 71% (29 of 41) of high-income and upper middle–income countries, in contrast to only 31% (11 of 35) and 14% (three of 22) of lower middle– and low-income countries, respectively (Figure 1B and Supplemental Figure 1A).

Renal Dietitians Practice Settings.

Overall, dietitians/renal dietitians were similarly available in inpatient and outpatient settings across countries in different World Bank income groups (Figure 1C) and around the world, except in Eastern and Central Europe, the Middle East, and North and East Asia regions where dietitians/renal dietitians appear to be much more available for inpatient than outpatient consultations (Supplemental Figure 1B). Across countries in different World Bank income groups, except low-income countries, dietitians/renal dietitians were generally more available for consultations with patients with CKD who were on dialysis than those who were not on dialysis (Figure 1C). Supplemental Figure 1C depicts kidney nutrition care across ISN regions for patients with CKD and those on long-term dialysis.

Global Comparison of Patients’ Out-of-Pocket Expenses per Dietitian/Renal Dietitian Consultation.

The median patients’ out-of-pocket expenses (costs that individuals pay out of their own cash reserves) per dietitian/renal dietitian consultation varied widely around the world (Table 3). Inpatient dietitian consultation costs were the lowest in lower middle–income countries and highest in low-income and upper middle–income countries. Among all ISN regions, patients’ out-of-pocket expenses were the highest in Latin America and the Caribbean region for inpatient dietitian consults, and in the Eastern and Central Europe region for outpatient dietitian consults (Table 3).

Table 3. - Global comparison of patient’s out-of-pocket expenses (in USD) per dietitian/renal dietitian consultation
Location Inpatient Cost (USD) Outpatient Cost (USD)
Median (IQR) n Median (IQR) n
Overall 20 (10–30) 25 20 (10–30) 34
ISN regions
 Africa 20 (13–25) 4 25 (20–40) 4
 Eastern and Central Europe 30 (25–35) 5 33 (30–35) 2
 Latin America and the Caribbean 40 (1–40) 3 18 (6–38) 8
 Middle East 30 (30–30) 3 30 (5–50) 3
 NIS and Russia 0 0
 North America 0 20 (20–20) 1
 North and East Asia 10 (10–15) 4 10 (10–10) 5
 Oceania and Southeast Asia 15 (10–20) 2 16 (9–20) 4
 South Asia 10 (3–20) 3 10 (5–10) 5
 Western Europe 8 (8–8) 1 17 (8–25) 2
World Bank groups
 Low income 30 (30–30) 1 18 (5–30) 2
 Lower-middle income 10 (5–20) 7 11 (8–18) 8
 Upper-middle income 30 (10–35) 9 20 (5–35) 11
 High income 20 (10–30) 8 20 (10–30) 13
USD, US dollar; IQR, interquartile range; ISN, International Society of Nephrology; NIS, newly independent states.

Personnel Other than Dietitians Involved in Giving Dietary Counseling.

Personnel other than dietitians are involved in giving dietary counseling to patients with CKD in 85% (131 of 155) of the countries around the globe. In 86% (49 of 57), 80% (33 of 41), 94% (33 of 35), and 73% (16 of 22) of high-income, upper middle–income, lower middle–income countries, and low-income countries surveyed, respectively, personnel other than dietitians were involved in giving dietary counseling (see Figure 1D and Supplemental Figure 1D).

Availability of Formal Nutrition Assessment Service and Tools

Formal Assessment of Nutrition Status.

There were global variations in the service availability of formal assessment of nutrition status in kidney care (Figure 2 and Supplemental Figure 2A). Overall, only 54% (83 of 155) of the countries provided formal assessment of nutrition status for patients with CKD.

F2
Figure 2.:
Global availability of various nutrition assessments. Having formal assessment of nutritional status and use of different nutrition tools, including change in body weight and serum albumin, for nutrition assessment across World Bank income groups.

Body Weight.

Monitoring of body weight was generally available in 77% (119 of 155) of the countries globally, and there were variations across different World Bank income groups (Figure 2 and Supplemental Figure 2B).

Serum Albumin.

Measurement of serum albumin was generally available in nearly all high-income and upper middle–income countries, but was available in only 68% (15 of 22) of low-income countries (Figure 2C and Supplemental Figure 2C).

Anthropometry.

Anthropometry was generally not available and never used in 56% (87 of 155) of all countries globally (Supplemental Figure 2D).

Body Mass Index.

Similar to body weight, body mass index was generally available in 79% (122 of 155) of all countries and was more available in higher-income areas (Supplemental Figure 2E).

Availability and Cost Coverage of Oral Nutrition Supplements

Oral nutrition supplements were generally available in 81% (126 of 155) of the countries globally and were more available in higher-income areas. Overall, only 52% (81 of 155) of the countries around the globe covered the cost of oral nutrition supplement for inpatients, and 25% (39 of 155) of the countries covered the cost of oral nutrition supplement for outpatients (Figure 3 and Supplemental Figure 3, A and B).

F3
Figure 3.:
Global availability and cost coverage of oral nutrition supplements. Oral nutrition supplement availability and cost coverage in inpatient and outpatient setting across different World Bank income groups.

Formal Communications between Nephrologists and Dietitians in Kidney Nutrition Care Delivery

Feedback to Nephrologists on Findings of Nutrition Assessment.

Notably, results of nutrition assessment performed by dietitians were frequently not reported back to nephrologists (Figure 4 and Supplemental Figure 4).

F4
Figure 4.:
Global interdisciplinary communications in relation to kidney nutrition care delivery. For countries with dietitians/renal dietitians available, feedback to nephrologists on findings of nutrition assessment, dietary prescriptions to patients with CKD, and dietary adherence of patients with CKD across different World Bank income groups.

Formal Communications on Dietary Prescription to Patients with CKD.

Overall, in only 8% (six of 75) of the countries that reported that dietitians/renal dietitians were available did formal communication “always” occur between dietitians and nephrologists regarding dietary prescriptions to patients with CKD. In 25% (19 of 75) of the countries, this communication “often” occurred, and this “sometimes” occurred in 60% (45 of 75) of the countries (Figure 4). Supplemental Figure 4B depicts formal communications between dietitians and nephrologists on dietary prescription to patients with CKD across different ISN regions.

Formal Communications on Dietary Adherence of Patients with CKD.

Overall, dietitians and nephrologists “always” communicated formally about patients’ dietary adherence in only 5% (four of 75) of the countries, “often” communicated in 27% (20 of 75) of the countries, and “sometimes” communicated in 65% (49 of 75) of the countries (Figure 4). Supplemental Figure 4C depicts formal communication with nephrologists on dietary adherence of patients with CKD across different ISN regions.

Discussion

This report confirms significant heterogeneity within each ISN region, across different ISN regions, and across World Bank income groups in the capacity and availability of kidney nutrition care services and in the formal communication pattern between dietitians and nephrologists in the delivery of kidney nutrition care.

Globally, 51% of the countries surveyed did not have dietitians/renal dietitians to provide this specialized nutrition service. The majority of low-/lower middle–income countries and close to half of the upper middle–income countries did not have dietitians/renal dietitians for consultation either in inpatient or outpatient settings for patients across the spectrum of CKD. Furthermore, dietary counseling by a person trained in nutrition was generally not available in a large proportion of the low- and lower middle–income countries and up to a third of the countries in upper middle–/high-income levels, confirming a large service gap in dietitian/renal dietitian counseling and monitoring worldwide. The finding is of particular importance because many of these countries also had limited access to KRT or could not afford dialysis (4,5,8). Using nutrition intervention to slow the progression of CKD and thereby delay the need for KRT are important treatment strategies in resource-constrained countries (Table 1) (9,11,2829–30). Having dietitians/renal dietitians to implement nutrition interventions and do regular dietary counseling in the outpatient setting is an essential aspect of meeting treatment goals in multidisciplinary CKD care (31). Studies have shown cost effectiveness of implementing nutrition intervention in different kidney disease groups (3233–34). One out of every four patients with an eGFR of <30 ml/min per 1.73 m2 treated with nutrition intervention would be prevented from starting dialysis in both intention-to-treat and per-protocol analyses (35). Reducing the need for dialysis would translate to substantial health care cost savings globally.

Given the global shortage of dietitians/renal dietitians and limited availability of dietary counseling services, a large proportion of countries, especially low-/lower middle–income countries had nephrologists and nurses rather than dietitians providing most of the dietary counseling to patients with CKD. Notably, non-nephrology physicians gave most of the dietary counseling in nearly one third of low-income countries. It is essential to have global advocacy for governments to prioritize funding and workforce resources to build the capacity and infrastructure required for implementation of kidney nutrition care, not only to increase training and credentialing of registered kidney dietitians but also to provide general training of nutrition intervention to health professionals who are involved in kidney nutrition care, especially in resources-restricted countries. Because diets vary around the world, it is essential that dietitians and health professionals involved in kidney nutrition care receive appropriate, local, specialized or general training relevant for their clinical practice and implementation. Particularly in resource-restricted countries that lack renal dietitians, where health professionals (including general dietitians, nurses, nephrologists, or non-nephrology physicians) are very often tasked to implement kidney nutrition care, such health professionals should receive appropriate training and have the required credentialing and certification before doing so (36). Online practical training programs, workshops, and practical tool kits in nutrition management developed by professional organizations may help to rapidly scale up the task-shifting capacity for kidney nutrition care in lower-resourced settings. Simple and easy-to-understand infographics on food and diet tips specifically for patients in emerging countries may help fill the gaps more immediately until more professional nutrition training is scaled up.

Nutrition assessment is essential for tailoring nutrition interventions in patients with CKD and for identifying those who are at risk of, or who currently experience, protein-energy wasting to provide appropriate nutrition management (37). This survey demonstrated significant global variations in the availability of formal nutrition assessment in kidney care and a huge gap in formal nutrition assessment services worldwide, especially in low- and lower middle–income regions, such as Africa, the newly independent states, and Russia. The exact reason for these variations is not defined but may relate to a lack or shortage of dietitians/renal dietitians to conduct formal nutrition assessments, or a lack of awareness by nephrologists/non-nephrology physicians concerning referral of patients with CKD/kidney failure to dietitians for formal nutrition assessment. Body weight and serum albumin were among some of the key parameters proposed by the ISRNM to define protein-energy wasting (37), and the recent Kidney Disease Outcome Quality Initiative guideline suggested serum albumin as a marker of hospitalization and death (38). Given that body weight and body mass index assessment are not costly and are easy to measure, we recommend relying on them to assess and monitor nutrition status in CKD/kidney failure, especially in economically constrained countries.

The survey showed significant global variations in the availability of oral nutrition supplements. The use of oral nutrition supplements improved protein and energy balance in patients on dialysis (19,20) and has been shown to reduce hospitalization (22). More high-income than low-income countries provided such supplementation free of charge. It was also available free of charge more in the inpatient setting than in the outpatient clinic/office. In low-income and lower middle–income countries, it was mostly not free of charge for patients in either setting. These findings suggest practical cost barriers and highlight challenges many low-/lower middle–income countries face in managing kidney failure populations at risk of, or complicated by, protein-energy wasting, whose nutritional needs are not sufficiently met by diet alone. One possible solution to overcome this barrier could be to develop homemade nutrition supplements (using blenders), with dietitians providing guidance regarding their composition.

The study identified significant gaps in formal interdisciplinary communication between nephrologists and dietitians globally. This would adversely affect the effectiveness and quality of kidney nutrition care delivery. The data highlight the need to improve interdisciplinary communication and, preferably, to develop structured communication between nephrologists and dietitians to facilitate kidney nutrition care delivery to patients with CKD/kidney failure. An example would be to develop a structured, standardized template for the information that is required to be regularly communicated between nephrologists and dietitians from either side. This would enable a clear, individualized nutrition management objective and kidney nutrition care plan to be set up for each patient that is informed by both disciplines and facilitates more effective communication and implementation of multidisciplinary kidney nutrition care.

This survey represents the largest and most comprehensive study to date that examined current global availability and capacity of kidney nutrition care services. Major strengths include a high response rate from a large number of key national and regional stakeholders, including nephrologist leaders, health care policy makers, and consumer representative organizations who broadly represent a large portion of the global kidney community. The limitations of this study also need to be considered. First, the nature of the survey and some questions in the survey required respondents to have practical knowledge and expertise or perceptions in CKD management and kidney nutrition care. To optimize the quality of the information obtained, respondents with different types of expertise and regional representations were carefully selected on the basis of communications with ISN regional boards. Any discrepant responses between respondents within countries were resolved by teleconference with regional board representatives. The scope of the current survey was limited to patients with CKD and kidney failure receiving maintenance dialysis therapy and did not include patients with AKI or kidney transplantation. Furthermore, the survey may have been subjected to demand characteristics and response bias, including social desirability bias. Such biases were mitigated by corroboration and validation of findings at the country level with regional leaders and the published literature. In addition, systems often vary within countries, and responses from a country or regional level might not be fully correct and there is often heterogeneity even within countries. Some questionnaire items, such as communication between nephrologists and dietitians, might be difficult to measure and were likely heterogeneous within countries. Furthermore, the survey did not include specific questions on health insurance policies.

This report has several key implications. It calls for a joint effort to raise global awareness of the importance of kidney nutrition assessment and care in CKD/kidney failure management among health policy makers, health care professionals, patients, and their families. Nutrition intervention slows CKD progression, reduces kidney failure/death, delays the need for KRT (7), and allows for better symptom control in patients receiving conservative kidney care. The findings form an important basis to increase global advocacy of government prioritization of funding resources and renal dietitians’ manpower and training to improve global kidney nutrition care. Education and training programs with certification and credentialing are required to equip health professionals across disciplines with the required skills and knowledge before they contribute to kidney nutrition care delivery in the face of shortages or lack of renal dietitians in resource-constrained countries. In the long term, the definitive solution to the foregoing problem is to train and provide salary support for adequate numbers of qualified dietitians who have undergone specialized training in kidney nutrition to implement nutrition intervention across the spectrum of CKD. A multidisciplinary approach should be promoted to facilitate more interdisciplinary communication between nephrologists and dietitians in global kidney nutrition care delivery.

In conclusion, this study demonstrates significant heterogeneity in global kidney nutrition care and suboptimal kidney nutrition care in many parts of the world, especially in lower-income countries. There is a significant global shortage or lack of dietitian/renal dietitian expertise; many patients with CKD who need nutrition intervention either do not receive it or receive suboptimal therapy with inadequate monitoring. Because oral nutrition supplements are not free of charge in many countries, especially low-income countries and for outpatients, this poses a huge challenge in managing patients with CKD/kidney failure who have protein-energy wasting. The data call for a concerted effort to increase global advocacy for governmental allocation of resources and prioritization of kidney nutrition care services, to increase training of renal dietitians, to improve access to kidney nutrition care, and to promote more structured interdisciplinary communication between nephrologists and dietitians to improve global kidney nutrition care. This report provides an important advocacy tool to promote and improve global access to kidney nutrition care.

Disclosures

A.K. Bello reports receiving honoraria from Amgen, Janssen, and Otsuka and serving as an associate editor of Canadian Journal of Kidney Health and Disease and as cochair of ISN GKHA. K. Campbell reports serving as a scientific advisor or member of Dietitians Australia and being employed by Metro North Hospital and Health Service. S. Damster reports being employed by ISN. D. Fouque reports serving as an advisory board member of Astellas, AstraZeneca, Lilly, and Sanofi; having consultancy agreements with AstraZeneca, Astellas, Fresenius Kabi, Lilly, and Sanofi; receiving honoraria from AstraZeneca, Fresenius Kabi, Lilly, and Sanofi; serving as a scientific advisor or member of AstraZeneca, Kabi, and Sanofi; receiving lecture fees from BBraun, Fresenius Kabi, and Vifor; and receiving research funding from Fresenius. A.N. Friedman reports having ownership interest in Eli Lilly; serving on editorial boards for Frontiers in Nephrology and Journal of Renal Nutrition, as a scientific advisor or member of GI Dynamics Scientific Advisory Board, and as a council member of the ISRNM; having consultancy agreements with Goldfinch Bio; and having other interests in/relationships with Watermark Research Partners by serving as a data safety and monitoring board (DSMB) member. G. Garibotto reports serving as a scientific advisor or member of editorial boards for BMC Nephrology, Journal of Clinical Medicine, Journal of Nephrology, and Journal of Renal Nutrition; having consultancy agreements with Fresenius Kabi; and serving as secretary and a council member of ISRNM. F. Guebre-Egziabher reports serving as a member of the Ethio-American Doctors Group, as a board member of the Ethio-American doctors fund, and as a member of the Francophone Society of Nephrology, Dialysis and Transplantation. D. Harris reports serving as past president of ISN. K. Iseki reports receiving honoraria from Bayer, Chugai, Daiichi Sankyo, Genzyme Japan, Kyowa Hakko Kirin, Otsuka, and Teijin; having consultancy agreements with HekaBio Inc. and Kyowa Hakko Kirin; and being employed by Nakamura Clinic. V. Jha reports receiving honoraria from AstraZeneca, Baxter Healthcare, and NephroPlus; receiving grants from Baxter Healthcare, Biocon, and BSK; receiving research funding from Baxter and GlaxoSmithKline; being employed by the George Institute for Global Health India; and serving as a scientific advisor or member of NephroPlus. K. Jindal reports receiving research funding from Amgen and Rockwell and honoraria from Amgen, Boehringer Ingelheim, and Lilly. D.W. Johnson reports serving as a scientific advisor or member of American Journal of Kidney Disease, CJASN, Cochrane Kidney and Transplant Group, National Health and Medical Research Council Academy, and Peritoneal Dialysis International; receiving travel sponsorships from Amgen; having other interests/relationships with Amgen (accommodation sponsorship), Australian and New Zealand Society of Nephrology (as president), International Society for Peritoneal Dialysis (ISPD; immediate past president), ISN (as past councillor), and Kidney Health Australia (advisor); having consultancy agreements with AstraZeneca, AWAK, Bayer, and Lilly; serving as Australian and New Zealand Society of Nephrology Councillor, the immediate past president of the International Society of Peritoneal Dialysis, and past ISN councillor; being a current recipient of an Australian National Health and Medical Research Council Practitioner Fellowship; receiving research funding from Baxter and Fresenius; serving on speakers bureaus for Baxter Healthcare and Fresenius Medical Care; receiving consultancy fees, research grants, speaker’s honoraria, and travel sponsorships from Baxter Healthcare and Fresenius Medical Care; receiving honoraria from Baxter, Fresenius, and Ono; and receiving speaker’s honoraria and travel sponsorships from ONO. K. Kalantar-Zadeh reports receiving honoraria and/or support from Abbott, Abbvie, ACI Clinical (Cara Therapeutics), Akebia, Alexion, Amgen, Ardelyx, AstraZeneca, Aveo, BBraun, Chugai, Cytokinetics, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hospira, Kabi, Keryx, Kissei, Novartis, Pfizer, Regulus, Relypsa, Resverlogix, Sandoz, Sanofi, Shire, Vifor, UpToDate, and ZS-Pharma; serving as a scientific advisor or member of Abbott, Abbvie, American Journal of Kidney Diseases, American Journal of Nephrology, Amgen, Ardelyx, AstraZeneca, Aveo, Cardiorenal Medicine, CJASN, Daiichi Sankyo, DaVita, Fresenius, Genetech, Hospira, International Urology and Nephrology, JASN, Journal of Renal Nutrition, Journal of Cachexia, Sarcopenia and Muscle, Keryx, Kidney International, Kidney International Reports, Nature Reviews Nephrology, Nephrology Dialysis Transplantation, several National Institutes of Health (NIH) study sections, National Kidney Foundation (NKF), Relypsa, Resverlogix, RUN, Sanofi, Seminars in Dialysis, Shire, Vifor, and ZS-Pharma; receiving honoraria from Abbott, Abbvie, Amgen, American Society of Nephrology, Ardelyx, AstraZeneca, Aveo, Baxter, Daiichi Sankyo, DaVita, Fresenius, Genetech, Hospira, Keryx, NIH, NKF, Relypsa, Resverlogix, Sanofi, Shire, Vifor, and ZS-Pharma; having consultancy agreements with Abbott, Abbvie, Amgen, Ardelyx, AstraZeneca, Baxter, Daiichi Sankyo, Fresenius, Hospira, Keryx, Otsuka, Resverlogix, Sanofi, Shire, and Vifor; receiving research funding from Dexcom and NIH; serving on speakers bureaus for Akibia, Daiichi Sankyo, Fresenius, Keryx, Relypsa, Sanofi, Shire, and Vifor; and having patents and inventions involving prognostic assays for maintenance hemodialysis patients. B. Kistler reports receiving research funding from Academy of Nutrition and Dietetics and serving as a scientific advisor or member of Academy of Nutrition and Dietetics, ISRNM, and Journal of Renal Nutrition. J.D. Kopple reports having other interests/relationships with Alpha Omega Alpha, American College of Physicians, American Society for Clinical Investigation (Emeritus), American Society for Nutrition, American Society of Nephrology, Association of American Physicians, International Federation of Kidney Foundations, International Society for Renal Nutrition and Metabolism, ISN, and NKF; having consultancy agreements with, having ownership interest in, receiving honoraria from, and serving as a scientific advisor or member of Nephroceuticals; and receiving a research grant from Shire Pharmaceuticals. C.P. Kovesdy reports having consultancy agreements with Abbott, Akebia, Ardelyx, AstraZeneca, Bayer, Boehringer Ingelheim, Cara Therapeutics, CSL Behring, GlaxoSmithKline, Rockwell, and Vifor; receiving honoraria from Abbott, Akebia, AstraZeneca, Bayer, Cara, CSL Behring, Rockwell, and Vifor; serving on the editorial boards of American Journal of Kidney Disease, International Urology Nephrology, Kidney International Reports, Kidney Medicine, and Nephrology Dialysis Transplantation; receiving research funding from AstraZeneca, Bayer, Gilead, and GlaxoSmithKline; serving as an associate editor of CJASN and Nephron; being employed by Memphis Veterans Affairs Medical Center, University of Tennessee Health Science Center; and receiving royalties from Springer and UpToDate. M. Kuhlmann reports receiving honoraria from Amgen, Bayer Pharma AG, Berlin Chemie, Fresenius, Hexal, ICU Medical, and Medice; serving on a speakers bureau for Fresenius Medical Care; having consultancy agreements with ICU Medical; and being employed by Vivantes Klinikum im Friedrichshain. A. Levin reports having other interests/relationships with the steering committee of the ALIGN trial, the Canadian Society of Nephrology, CREDENCE National Coordinator from Janssen (directed to her academic team), ISN, Kidney Foundation of Canada, NIDDK CURE Chair Steering Committee, and DSMB chair of the RESOLVE trial (Australian Clinical Trial Network); receiving honoraria from AstraZeneca, Bayer, Fresenius, Janssen, and NIH; receiving research funding from AstraZeneca, Boehringer Ingelheim, Canadian Institute of Health Research, and Kidney Foundation of Canada; serving as a scientific advisor or member of AstraZeneca, Boehringer Ingelheim, Chinook Therapeutics, GlaxoSmithKline, Reata, and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); having consultancy agreements with Bayer, Chinook Therapeutics, NIH, and Reata; being employed by BC Provincial Renal Agency, Providence Health Care, and University of British Columbia; and serving on the DSMB for ISN Research Committee, Kidney Precision Medicine, Kidney Scientist Education Research National Training Program, NIDDK, and University of Washington Kidney Research Institute Scientific Advisory Committee. M. Lunney reports being employed by Alberta Health Services and University of Calgary. D. Mafra reports being employed by Federal University Fluminense and serving as a scientific advisor or member of International Urology and Nephrology and Nephrology Dialysis Transplantation. L.W. Moore reports receiving honoraria from, serving as a scientific advisor or member of, and having other interests/relationships with the NKF. I.G. Okpechi reports receiving honoraria from AstraZeneca (South Africa) and Fresenius Medical Company. S.R. Price reports serving as a scientific advisor or member of American Journal of Physiology-Cell Physiology, Journal of Renal Nutrition, and Physiological Reviews, and as president-elect of ISRNM. A. Steiber reports being employed by the Academy of Nutrition and Dietetics; receiving research funding from the Academy of Nutrition and Dietetics Foundation, Anjinomoto, Commission on Dietetic Registration, Gates Foundation, National Institute of Child Health and Human Development, and NIH; serving as a scientific advisor or member of the American Council on Exercise scientific advisory panel and of the Journal of Renal Nutrition editorial board; and having ownership interest in Nephroceuticals. A.Y.-M. Wang reports serving as a scientific advisor of member of editorial boards for American Journal of Nephrology, Biomedicine Hub, Blood Purification, CJASN, EMJ Nephrology, JASN, Journal of Diabetes, Journal of Geriatric Cardiology, Journal of Nephrology, Journal of Renal Nutrition, Kidney International, Nephrology Dialysis Transplantation, and Nephron Clinical Practice (associate editor); serving as committee member of International Society of Nephrology (ISN)-Advancing Clinical Trials (ACT), deputy chair of ISN North and East Asia Regional Board, deputy chair of the ISN Education Working Group, council member of International Society of Peritoneal Dialysis (ISPD), president of the International Society of Renal Nutrition and Metabolism (ISRNM), and executive committee member of SONG Initiatives; and having other interests/relationships as committee member of ISN-ACT, deputy chair of ISN Education Working Group, deputy chair of ISN regional board, council member of ISPD, president of the ISRNM, member of SONG-HD CVD Outcome Measures Working Group, executive committee member of SONG Initiatives, and member of SONG-PD Working Group. C. Wanner reports receiving honoraria for steering committee and advisory board membership, lecturing, and travels from Akebia, AstraZeneca, Bayer, Boehringer Ingelheim, Fresenius Medical Care, Gilead, GlaxoSmithKline, Lilly, Sanofi-Genzyme, and Vifor; having consultancy agreements with Akebia, Bayer, Boehringer Ingelheim, Gilead, GlaxoSmithKline, MSD, Sanofi-Genzyme, Triceda, and Vifor; receiving honoraria from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Chiesi, FMC, Eli Lilly, Sanofi-Genzyme, and Shire-Takeda; having other interests/relationships with European Renal Association–European Dialysis and Transplant Association; and receiving research funding from Idorsia (grant to institution) and Sanofi-Genyzme (grant to institution). All remaining authors have nothing to disclose.

Funding

The GKHA project was supported by the University of Alberta (via the ISN) grant RES0033080. The ISN provided administrative support for the design and implementation of the study and data collection activities. The Global Kidney Nutrition Care Atlas was supported by the ISRNM using a Fresenius Kabi educational grant to ISRNM.

Published online ahead of print. Publication date available at www.cjasn.org.

See related editorial, “Accessibility of Nutrition Care for Kidney Disease Worldwide,” on pages .

Acknowledgments

We thank Sandrine Damster (senior research project manager at the ISN) and Alberta Kidney Disease Network staff (G. Houston, S. Szigety, and S. Tiv) for helping to organize and conduct the survey and providing project management support; Jo-Ann Donner (Awards, Endorsements, ISN-ANIO Programs Coordinator) for helping with the manuscript management and submission process; Charu Malik (ISN Executive Director) for her support; Syed Saad and Deenaz Zaidi for preparing the graphics work of the manuscript; and the ISN GKHA Steering Committee, executive committee of the ISN, ISN regional leadership, and the leaders of the ISN affiliate societies at the regional and country levels for their help, particularly with identification of survey respondents and data acquisition, which ensured the success of this initiative. None of the persons acknowledged received compensation for their role in the study.

Dr. A.Y.-M. Wang and Dr. C.P. Kovesdy developed the questionnaire for the Global Kidney Nutrition Care Atlas. The full council of the ISRNM and the ISN GKHA Steering Committee reviewed and approved the questionnaire.

The ISN provided administrative support for the design and implementation of the study and data collection activities. The authors were responsible for data management; analysis and interpretation; manuscript preparation, review, and approval; and the decision to submit the manuscript for publication.

Fresenius Kabi had no role in the design of the study and development of questionnaires; collection, analysis, and interpretation of the data; or in the preparation, approval, and submission of the manuscript.

Dr. A.K. Bello and Dr. D.W. Johnson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis; Dr. A.K. Bello, Dr. A. Levin, Dr. D. Harris, and Dr. D.W. Johnson contributed to the study concept and design of ISN GKHA; all the authors contributed to the acquisition, analysis, and interpretation of data and to the critical revision of the manuscript for important intellectual content; Dr. A.Y.-M. Wang contributed to the concept and design of the Global Kidney Nutrition Care Atlas; Dr. A.Y.-M. Wang drafted the manuscript; F. Ye conducted the statistical analyses; Dr. A.K. Bello, Dr. A. Levin, and Dr. D.W. Johnson obtained funding; Dr. A.Y.-M. Wang and Dr. C.P. Kovesdy obtained funding for the Global Kidney Nutrition Care Atlas; M.A. Osman, M. Lunney, and F. Ye provided administrative, technical, and material support; and cochairs Dr. A.K. Bello and Dr. D.W. Johnson of the ISN’s GKHA supervised the study. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted; Dr. A.K. Bello is the guarantor.

Because Dr. Csaba P. Kovesdy is an associate editor of CJASN, he was not involved in the peer-review process for this manuscript. Another editor oversaw the peer review and decision-making process for this manuscript.

Data Sharing Statement

The data collected for this study, including individual patient data and a data dictionary defining each field in the dataset, may be made available to others.

Supplemental Material

This article contains the following supplemental material online at http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.07800621/-/DCSupplemental.

Supplemental Appendix 1. Global Kidney Nutrition Care Atlas Questionnaire.

Supplemental Table 1. Detailed response rates to individual nutrition questions.

Supplemental Figure 1. (A) Availability of dietary counseling by a person trained in nutrition (this include renal dietitians, general dietitians, nutritionists, or nutrition technicians) for different ISN regions; (B) kidney dietitian practice settings for different ISN regions; (C) kidney nutrition care availability for nondialysis CKD versus dialysis patients for different ISN regions; and (D) personnel other than dietitians involved in kidney nutrition care across different ISN regions.

Supplemental Figure 2. (A) Doing formal assessment of nutrition status across ISN regions; and use of different nutrition assessment tools across ISN regions: (B) body weight, (C) serum albumin, (D) skinfold anthropometry, and (E) body mass index across ISN regions.

Supplemental Figure 3. (A) Oral nutrition supplements availability, and (B) cost coverage in inpatient and outpatient setting across ISN regions.

Supplemental Figure 4. Formal feedback to nephrologists on (A) findings of nutrition assessment, (B) dietary prescription to CKD patients, and (C) dietary adherence of CKD patients, across ISN regions.

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Keywords:

chronic kidney disease; kidney nutrition care; global; dietitians; nutrition supplement; renal nutrition; global health; nutritional status

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