Expert Q&A: The State & Future of Nutrition in Kidney Health

5 Clinical Experts Share Their POVs on Progress & Pitfalls in Renal Nutrition

Welcome to the first of many expert-led conversations from Signals slated for 2024 that asks community leaders to weigh-in on pitfalls, progress, and potential in their respective realms of the Kidneyverse.

As the title suggests, this conversation explores the vital role of nutrition in kidney health, as told through the firsthand perspectives of frontline clinicians across the care landscape. My goal is to use these group formats to shine a bright, balanced light on the most pressing topics in the kidney community today.

Many of you know that nutrition plays a vital (if not central) role in helping people manage their kidney health, from the earliest stages of kidney disease to those living with kidney failure. Recent clinical practice guidelines make that point clear. And still, despite its benefits, we can see just how far we have left to go to bring individualized nutrition to those who need it most.

Without further ado, let’s meet our guides for today’s journey to this delicious, nutritious, and bittersweet corner of the Kidneyverse.

Meet our experts

Our guests today represent a broad range of insights and experiences. They have worked as independent practice owners and on multidisciplinary care teams, within large health systems and in rural community clinics, for non-profits and Fortune 500s. I’m grateful to each of these experts for sharing their earned wisdom and insights with all of us.

• Rory Caswell Pace, MPH, RD, CSR, FAND, FNKF\

• Bethany Keith, MS, RDN, LD, CNSC

• Karla Rippchen, MBM, RDN

• Jill Sher, RDN, LD

• Cory Zenner, RD

What you’ll learn

• Current approaches to nutrition management in CKD/ESRD

• Barriers to effective management at multiple levels

• Role and impact of individualized nutrition planning

• How policy and systemic changes might improve access

• Where technology and innovation support better care

• Emerging trends and their potential impact

• Personal insights and anecdotes

• Resources & discussion

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Q&A

Q1. Thinking big picture here. How would you describe your approach to nutrition management for people with kidney disease?

TLDR: Our experts underscore the strategic importance of a personalized approach. They advocate for individualized goals and using Medical Nutrition Therapy (MNT) not just as a treatment modality, but as a fundamental part of a broader strategy to enhance kidney health. Their approaches balance clinical insights with a focus on understanding each patient's unique dietary preferences and lifestyle, moving away from rigid food restrictions towards a more nuanced understanding of nutrition's role in kidney health.

Rory: I am a strong advocate for the role of nutrition in management of CKD. I am also an advocate of using individualized goals and interventions to empower patients to be successful in their kidney disease and health journeys. Registered dietitians (RDs) with expertise in kidney disease are uniquely positioned to support patients in developing these individualized goals and plans. Nephrology RDs generally have broad knowledge of not only kidney disease but also of the numerous chronic conditions and comorbidities associated with CKD. As a result, nephrology RDs effectively function as care managers (when given the opportunity).

Karla: I would describe my current approach as individualized care that is client empowering. Having a kidney disease diagnosis does not mean memorizing the avoid food lists. Rather, eating a variety of foods with portion sizes based on your lab trending is the best way to feel your best. A variety of foods allows your body to absorb macro and micro-nutrients that your body needs on a daily, weekly and monthly basis.

Medical Nutrition Therapy (MNT) is a key component of disease management that allows me as a Registered Dietitian to bill Medicare insurance for nutrition education that is fine tuned to each unique client.¹

• “M” stands for Medical, and this is where I analyze objective date using two or more lab draws to review if labs are trending into or out of range. I will also sometimes ask the client for a week of food log tracking using the free app Cronometer in order to review micronutrients if these lab results are not available.

• “N” is for Nutrition, and this is where I interview the client and understand their unique culture; food tastes; (dis)likes due to texture, taste or previous life event; food intake timing of the day; type of food stores, budget, kitchen set up, and support persons.

• “T” is for Therapy. Nutrition therapy is where the magic happens and progress is made! Changing food habits, food lifestyle and overcoming hiccups along the road in order to make progress occurs with food therapy. Spending time with each client to understand their unique hurdles and challenges to help sort out what food bias that the client has absorbed is key.

There is well intentioned-but-confusing (and contradicting) information about food and kidney disease on the internet. Outdated food lists that severely restrict food choices are sometimes provided by health care workers who are not up to date on statistically significant food and nutrition science and kidney disease. As a Registered Dietitian Nutrition specializing in kidney disease, I review the science of how food is used by the body or excreted thru the urine or stool. Each stage of CKD changes how the body metabolizes food. Chronic diseases like kidney disease deplete the body of many nutrients that are not regularly monitored yet can alter gut health, sleep, mood, energy, healing power, and ability for a medicine to work efficiently.

Cory: I like to start out with building trust and rapport with any new patient and assuring them that there are no "good" or "bad" foods. I want them to walk away from our appointment with the tools to choose foods that help them feel their best. It is never my goal to give people an exact meal plan or "diet." Instead, I want them to gain exposure to nuanced nutrition information and hone skills such as label reading and recipe modification. In terms of topics covered, the foundation of any renal nutrition education I provide starts with reducing sodium intake, increasing fruit and vegetable intake, drinking the right amount of fluid, and eating adequate (not excessive) amounts of protein.

Bethany: As a dietitian, my current focus is split between providing 1:1 MNT and creating educational resources for people living with kidney disease. I create content for our social media channels, our blog, and our newsletters.

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Q2. What do you see as the biggest barriers to effective nutrition management in kidney care today?

TLDR: Our experts identify several key barriers to effective nutrition management in kidney care, including lack of awareness about the impact of Medical Nutrition Therapy (MNT), limited access to dietitians, insurance complexities, and low utilization of available resources. They stress the importance of provider and patient education, early intervention, and recognizing the critical role nutrition plays in delaying or managing kidney disease.

Rory: Research conducted and published jointly by NKF and the Academy of Nutrition and Dietetics showed lack of knowledge of coverage of MNT on the parts of patients and providers, and even among some dietitians. This work also revealed some lack of knowledge of evidence-based interventions that impact clinical outcomes.

The research referenced above also revealed a lack of provider resources, meaning limited access to dietitians with expertise in kidney disease, particularly in the earlier stages prior to renal replacement therapy. My own experience in talking with nephrologists and launching a business focused on MNT for CKD mirrored the findings in the surveys. Nephrologists have had some unfavorable experiences in referring their patients to RDs who are generalists or are specialists in areas other than kidney disease, which has negatively impacted referral behaviors. Nephrologists with who I have spoken are very enthusiastic about the idea of having access to a dietitian knowledgeable/specializing in kidney disease as a partner in the care of their patients.

Insurance coverage. Though insurance itself is generally not a barrier, it is regularly perceived as such. That said, insurance coverage is rarely straightforward, which can create a barrier to patients seeking care. Of note, fee-for-service Medicare covers MNT for people with CKD stages 3-5 not on dialysis and 3 years post-transplant in a fairly straightforward and comprehensive manner, with no out of pocket expense to the patient (20% coinsurance is waived in accordance with ACA as this is considered a preventive service).

Low utilization. Available as a benefit for this population since approximately 2002, MNT has been historically underutilized by beneficiaries with CKD. From USRDS data, utilization remained <10% for many years and has slowly increased over the past few years, though utilization remains <19% per the last USRDS Annual Report.

Provider perception and influence. In my experience, not all nephrologists are aligned with the evidence-based nutrition interventions that can help delay or prevent progression of CKD. The voice of the physician is influential; if the nephrologist mentions even indirectly to their patient that nutrition does not have an impactful role in management of CKD (or underlying chronic conditions), patients are unlikely to seek out or follow through with MNT as a part of their plan of care. In these situations, the requirement for a physician referral for MNT by Medicare as well as some individual states can create barriers to access to care. There is also an influence of primary care providers. Some primary care physicians delay referral to nephrologists until CKD is very advanced, which has the net result of patients potentially missing out on MNT as part of their CKD plan of care. Lastly, due to some unintended incentives in traditional ESRD payment models, nephrologists may focus more on patient placement on dialysis than on engaging strategies such as MNT to delay CKD progression.

Patient perception. In my experience, CKD is a challenging condition in which to educate and support patients/clients. Because it is often an invisible condition in the earlier stages, it can be challenging to engage patients/clients in health-related behavior change in CKD. In New Day Nutrition (now closed), we experienced that there was a subgroup of patients referred for MNT who were not ready to consider nutrition-related behavior changes for CKD; in some cases this changed as their stage of CKD advanced. We also identified a subset of patients in earlier stages of CKD and/or early in their CKD diagnosis/journey who were very motivated and sought out MNT services to support their CKD management.

Karla: First and foremost, a lack of public awareness of their own kidney health. The majority of clients I work with did not know they had kidney disease until stage 4 (severe) kidney disease. If a patient is on medications for blood pressure, diabetes, high cholesterol— do they know where their kidney health is this year compared to last year?

The public is generally aware of the connections between [glucose + diabetes], or [cholesterol / blood pressure + heart health]. It would be fantastic to get to a place where the public recognizes similar connections between [eGFR / uACR + kidney health].

Second, dietitians and providers work brilliantly as a team to provide high quality health care; however, many insurances require a provider referral for nutrition counseling. That means provider buy-in is essential. In an ideal world, every provider would ask their patient if they wanted to see a Registered Dietitian specializing in kidney disease.

Cory: I think the largest barrier is the lack of provider buy-in on how great an impact MNT can have on delaying CKD progression. I see so many patients at point of transplant evaluation who have never seen a renal dietitian and they frequently ask, "why has nobody mentioned this to me before?"

I also think that there is a general misunderstanding of what 1:1 counseling by an RD looks like. I frequently see that a physician encourages a low sodium diet, but it's the RD that teaches a patient what that means and how to implement it into their lifestyle.

Bethany: The biggest barriers are patient access along with provider knowledge of coverage and the impact that nutrition can have on the progression of kidney disease.

Jill: Overall, healthcare is going through some much-needed changes. A lot of issues that had been on the “Discuss List” before COVID were moved to the forefront of the “To-Do” List!

Things like (a) Patient Access to Technology, (b) Seamless Transitions for Reimbursements for MNT in Healthcare Systems; (c) Logistics of Scheduling Patients if going through a physician's office, (d) staff shortages, and (e) knowledgeable staff in CKD.

Also, a big one is making referring providers aware of renal dietitians (RDs) available for Telehealth in the providers' areas.

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From Jimenez et al (2021)

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Q3. Let’s get specific and talk about the role of individual nutrition planning. Why is it important within kidney care compared to a one-size-fits-all approach?

TLDR: Experts unanimously agree on the vital importance of individualized nutrition planning in kidney care. Emphasizing the diversity of dietary needs across different stages of kidney disease and (often) coexisting health conditions, they highlight the necessity of tailoring nutrition plans to each patient's unique clinical status, lab values, and personal factors like food preferences and access. It's about translating nutritional science into tangible, daily practices that resonate with and adapt to the unique circumstances of each patient.

Rory: There are so many reasons that individualized nutrition care is important in kidney disease. First and foremost, I think about the role that food plays in our lives and all of the factors that influence the food choices we make. There are factors that are more positively connotated, such as culture, tradition, and celebration. There are what might be considered neutral factors, such as food preferences, allergies, or intolerances. There are also more problematic factors, such as food access, including impacts of structural racism. Considering all of the things food means to each individual, all of the "baggage" that may accompany food choices, and the addition of modified dietary needs related to CKD (and other chronic diseases), an individualized approach is absolutely essential for success.

I do believe there is a role for general education about nutrition and kidney disease. This may be a starting place for many people to begin contemplating changes in their nutrition plan to support their kidney health, and for some, it may be sufficient for them to implement and sustain a nutrition plan. I would venture to say the majority of people with CKD (or people!) require both more education about nutrition and CKD and more supportive counseling to facilitate nutrition-related behavior change.

As a nephrology dietitian*, one of my goals is to educate providers and the public that there is no longer one "renal diet" that is appropriate for all people with CKD or ESKD. Underlying conditions, nutritional status, and medications all impact CKD nutrition outcomes, and food preferences and access have equally important roles in an individual's nutrition plan. To provide equitable, inclusive, and effective nutrition care, our strategies must be individualized. (*this is also a shared goal of both the NKF Council on Renal Nutrition and the Academy of Nutrition and Dietetics Renal Dietitians Practice Group)

Karla: Kidney disease has 5 stages and each stage has different nutrient need calculations. Many patients with kidney disease also have other health diagnoses. Each health diagnosis combination may require a different nutrition plan with different nutrition needs. More importantly, each patient has different hurdles when working thru food barriers to change. Spending time to work through these food barriers is how progress is made towards improving kidney health. Health is volatile and what works with food and kidney health one month may not work in 6 months.

Cory: Individualized recommendations are so important because the renal diet is notoriously rigid— and if we can differentiate between CKD etiologies and monitor relevant nutrition related lab values, we can improve quality of life as well as clinical outcomes through diet liberalization.

Bethany: Individualized nutrition planning is crucial for any medical condition, and kidney disease is no exception. Many people living with kidney disease receive generalized nutrition recommendations that leave them feeling confused and frustrated. Renal dietitians are trained to provide individualized recommendations based on a person's laboratory values, clinical status, medications, and other important factors. Compared to a one-size-fits-all-approach, an individualized approach prevents complications related to kidney disease and improves quality of life.

Jill: When we give generalized recommendations and one-size-fits-all approaches on handouts, we find those same handouts in the trash can. Some people say “I already know this”, “I can Google that”, OR they are simply overwhelmed with a medical diagnosis and the multitude of recommended changes. Nutrition recommendations may change through the different stages of CKD 1-5 and an RD helps integrate medical history, psycho-social factors, labs, medications, and anthropometrics to Individualize Diet Recommendations.

Some patients will joke and say, “I was on a Cardiac, Renal, and Consistent Carbohydrate or Diabetic Diet in the Hospital so I think I can only eat Cardboard.”

He or she may add, “I can only eat Sugar-Free Jell-O, Lettuce, Chicken, and Scrambled Eggs. But, they weren't real eggs, it was powdered or liquid eggs and they had to be egg whites for heart health. I was told lettuce had too much fluid now that I am on dialysis. Jell-O is fluid too so I can't eat it very much. I know they sent me chicken, but I was told to only eat half because I have to eat less protein now that I am on dialysis.

Not to mention the evolving guidelines around things like protein. When I first started working with kidney patients, it was not common practice to encourage plant-based proteins on a low-protein or very low-protein diet with keto acid analogs supplementation for patients with CKD not on dialysis, without diabetes, and metabolically stable. It is now included in the most recent NKF-KDOQI Nutrition Guidelines for CKD. This is a situation where as a clinician I would want to evaluate the patient's readiness to make these types of changes because low protein can be a challenge for patients who might be used to otherwise.

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Q4. What policy or systemic changes are needed to improve access to nutrition therapy in kidney care? Where do current measures fall short?

TLDR: Our experts advocate for policy reforms like expanded Medicare coverage across all CKD stages, uniform insurance billing, and better integration of dietitians in early kidney care. They highlight these as key steps to improve accessibility and effectiveness of nutrition therapy in kidney care.

Rory:

1. Increase coverage of MNT by Medicare to all stages (1-5) and clarify that the benefit is extended to all beneficiaries with CKD5 NOT on dialysis (this is currently a grey area).

2. With the trends toward increasing enrollment in MA plans, there is a likelihood of increased variability in coverage of MNT for CKD. While MA plans do typically cover MNT for CKD, the number of visits may be more limited, and they are most likely subject to deductible and/or copay (as considered therapeutic vs. preventive by most payers).

3. Policy change to increase Medicare reimbursement for dietitians to 100% of the fee schedule (vs. 85%).

4. Ongoing advocacy work regarding the role and impact of MNT for CKD, perhaps through bringing more stakeholders together.

5. Focus on aggregating and publishing outcomes data related to MNT for CKD.

6. Policy changes related to Medicare's Kidney Diseases Education benefit: 1) qualify RDs as a provider of KDE; 2) waive coinsurance (which seems to be a huge barrier to beneficiaries using this benefit). A potential 3rd would be to increase the payment rates for KDE, as they appear to be too low to make economic sense for many providers.

7. Expansion of value-based care models that include nutrition care and/or outcomes related to nutrition. I understand there has also been discussion about a CMS quality metric related to pre-dialysis RD care, which would be a huge policy driver for MNT expansion.

8. Indirectly, the in-progress advocacy to expand Medicare MNT coverage to more conditions has potential to improve access to care for people with CKD by potentially increasing awareness and facilitating access to care that may be preventative at a more primary stage.

9. Single-payer healthcare? ;)

Karla: Uniform insurance billing for nutrition education is my dream. Each insurance has their own billing process in each state. Resubmitting rejected claims based on errors on my end or the insurance's end is very time consuming. I want to use my healthcare insurance when I need it so I will continue to work through the insurance reimbursement process as a private practice dietitian that bills insurances for nutrition education.

Bethany: Connecting people with kidney disease to a dietitian upon diagnosis would improve the effectiveness of nutrition therapy. The effectiveness would be amplified by identifying more people with kidney disease at earlier stages. To improve access to MNT, we need more dietitians trained in renal nutrition along with more dietitians available to people in rural areas. Although Medicare covers MNT for kidney disease, there are still some insurance policies in existence that do not cover any type of MNT. In addition, Medicare requires a referral from an MD, which may delay consultation with an RD. There is also a limit on the number of hours of MNT a person with kidney disease can receive each year.

Jill: Three things:

• Awareness of early screening for CKD

• Need for more Registered Dietitians trained in renal

• Sharing what's working and what's not with technology and AI

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Q5. Has recent technology innovation helped you deliver nutrition therapy treatments for your patients? If so, how?

TLDR: Technology, particularly telehealth, plays a varying role in delivering nutrition therapy for kidney patients. Experts note its benefits in increasing accessibility and convenience, though challenges like internet availability and patient familiarity with technology persist. They emphasize a balanced approach, integrating technology with traditional clinical skills to meet diverse patient needs."

Rory: I think this is another area where individualization is key. Considering that much of the CKD population consists of older adults, telehealth and other technology tools may or may not improve access to or effectiveness of nutrition care. In a study conducted at Satellite Healthcare on adoption of mHealth, it was found that while the majority of people on dialysis had smartphones, they used them for few purposes, which did not frequently include tools or activities related to managing their health/healthcare. While telehealth can increase access to care for people with limitations in mobility, transportation, or provider availability, use of telehealth does require some hardware, software, and knowledge that not all potential clients may have or may feel comfortable using. Some patients/clients continue to prefer and value in-person care, so I think it is important that we consider those preferences/needs in establishing services.

The same goes for apps-some people feel very comfortable using apps to track food, exercise, medication, etc. or to obtain medical/health information, while others may not. Specific to nutrition and CKD, there are limitations with food databases, which may have missing or inaccurate information for nutrients of importance to people with CKD, such as phosphorus or potassium.

There is a lot of potential for AI tools. Where nutrition is concerned, I think we are still exploring the capabilities. There is a great deal of interest in using AI tools and predictive modeling to risk-stratify people with CKD. In a value-based care organization/environment, this makes sense and has some value, but I don't think it's the end of the story. There is no substitute for experienced clinicians reviewing clinical data and interacting with clients to influence outcomes. As clinicians, we must find a balanced approach that incorporates technology tools with the most human of our clinical skills.

Karla: Nutrition education is a hands-off process and I find that telehealth is the ideal platform to reach patients. I can change the computer or phone screen to my education handouts/pull up a grocery store item and look at the label with patient/look inside a patient's fridge or cupboard if they want when a specific food question comes up. Telehealth allows the patient to save on vehicle expenses, time commuting, energy when they are not feeling well.

Most importantly, most of my kidney disease patients are retired and ask a loved one to take them to appointments. Telehealth allows their caretaker to only take a couple hours off work instead of the whole day. I also offer evening or weekend appointments and that has been convenient for the patients who also want a support person who may work full time sitting on the couch with them during the telehealth appointment. HIPAA compliant electronic charting and chat features allows seamless communication and document sharing with myself and the patient or provider.

Medicare is the only insurance that I am aware of that allows phone nutrition education if the patient or their support person does not have video capability. I then mail the nutrition education handouts to the patient. I have been pleasantly surprised that the rural population welcomes telehealth due to their long commutes to healthcare appointments.

Jill: Telehealth will continue to be a game-changer not only in delivering different healthcare services but also in providing CKD medical nutrition therapy & education. The barriers I have personally experienced are internet access and users' capabilities with telehealth. Wireless internet access isn't 100% available in small, remote, and/or rural areas. The map-dot town I grew up in doesn't have many options for internet access. I moved back to Tennessee after living in Dallas-Fort Worth for 12 years, and I was reminded of these Wi-Fi deserts. I have found most people in all age ranges do have cell phones that can be utilized for telehealth; however, the providers themselves or designated staff may have to devote some time to educating patients on the electronic appointment format and accessing education tools. This is pertinent since the CDC reports the largest group currently with CKD is 65+ at 34%.

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Q6. Looking ahead, which emerging trends or potential innovations in kidney nutrition excite you most?

TLDR: Experts are excited about future innovations in kidney nutrition, including the potential of value-based care models, expanded Medicare coverage, and new dietary interventions like plant-dominant diets. They also see telehealth as a key tool in providing specialized, accessible care, and envision technological advancements enhancing patient education and early intervention in kidney disease management.

Rory:

1. VBC demonstration models: I am eager to see the outcomes and, perhaps more importantly, the lessons learned from these models. MNT and RDs experienced with kidney disease have huge potential to impact outcomes of these models, including PAM, planned dialysis starts, reduced hospitalizations, and preemptive transplants.

2. The Medical Nutrition Therapy Act (currently in congress) to expand access to MNT for individuals with other diseases and conditions; and to allow services to be referred by other health professionals.

3. Emerging and/or growing evidence on specific nutrition interventions in CKD, such as plant-dominant or vegetarian diets to delay CKD progression, or ketogenic diets as an intervention in Polycystic Kidney Disease.²

Karla: Telehealth allows me to connect to kidney disease patients wanting nutrition education from many corners of the United States as I sit in my Iowa home office. I envision more specialized kidney care thru telehealth. I envision rural patients going to their local community hospital or library or court house to check in for a healthcare appointment that does not require hands on treatment every appointment.

I envision one key employee working at this location that puts the headset on a patient that will measure some of their health metrics. Or, the one employee starts a telehealth appointment by clicking on their computer screen for that elderly patient that doesn't have internet access or technology in their home.  

Visual and audio education seems to be preferred in 2024 with increased social media sites. Designing more interactive education that can be altered to each learning style in real time during the education session is a way to increase retention of new information and reduce communication error.

Jill: I get excited about the possibility of earlier referrals to RDs for education and monitoring to help delay the progression of CKD through nutrition!

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Q7. Story time! I’d love to hear about any experiences or situations where nutrition played a critical role in improving a patient’s life.

TLDR: These personal stories from our experts illustrate the transformative power of nutrition in kidney care. From stabilizing kidney function in advanced stages to managing critical symptoms and improving lab values, nutrition therapy has been pivotal in enhancing patient outcomes and quality of life, and underscores its integral role in managing kidney disease.

1. Rory: The family of a man in his mid-eighties with CKD5 sought out our RD/MNT services. Given his advanced age, this man did not desire to go on dialysis. He also expressed concern about following an overly-restricted or hard to follow diet. Working with our team for several months, he stabilized his GFR and adopted food and physical activity goals that aligned with his overall goals. He shared that he found the compassionate and individualized care to be key to his success.

2. Rory: A patient who was previously referred for MNT and declined experienced an advancing of his CKD to stage 5, and which point he accepted a new referral. He was experiencing signs of uremia and had some altered nutrition-related lab values. Though he only completed one MNT session prior to starting to dialysis, we were able to implement interventions to manage uremia and prevent worsening of abnormal labs, such as hyperkalemia or fluid overload that could have resulted in hospitalization. With side effects managed and stabilized, the patient was able to have a PD catheter placed and complete training, allowing for a planned dialysis start on a home therapy (and avoiding a hospitalization).

3. Rory: A patient with newly diagnosed CKD3 sought out MNT services with our organization, obtaining a referral from her nephrologist. Desiring face-to face visits, she drove approximately 2 hours each way for her appointments, for which she paid out of pocket. She implemented food choice and physical activity goals that helped her to stabilize her weight, improve the quality/variety of her diet, and improve her GFR to the degree to which, when she asked her nephrologist if her would provide a justification to her health plan to cover the service, he replied that they "probably wouldn't cover it [MNT] because her numbers were too good."

4. Jill: I love stories too and probably could write a book of some very fun ones and some very poignant ones. Numerous stories quickly come to my mind of patients who "crashed" onto dialysis without any knowledge of having CKD. Some were not consistently followed by primary care physicians, endocrinologists, and/or nephrologists. Some had primary care physicians and recalled labs within the past year, but most were not familiar with BUN/Cr and/or Creatinine Clearance. In my experience, few had received diet education other than education he or she may have received when they just discharged from the hospital. Another benefit of RD referral is not just education and reinforcement of diet, but also to identify possible medication issues. These can be relayed to other members of the team and the RD can provide additional support and accountability in this area.

5. Jill: This is more of an adjacent nutrition story and also illustrates opportunities for improvements. Anyone who has been in the "Kidneyverse 🤩" for some time is very tuned-in to risk factors for CKD with diabetes and high blood pressure topping the list. A long-time friend of mine who has had high blood pressure for ~10 years and takes multiple BP meds. She had an elevated HgbA1c >7 from a lab draw at her Primary Care Physician. She was never notified of this result. She had a 6-month follow-up and additional labs with the HgbA1c decreased to 6.3. To add to this: She works for a major health insurance company as an LMSW so she is very knowledgeable about healthcare, medications, and preauthorization. Her initial labs were not relayed. Yes, she could have requested them. However, I know she has chased down labs for one of her 3 children before. I am biased and defending her as my friend and a full-time working Mom. The other issue here is the insurance approval of some of the GLP-1 receptor agonists with her A1c documented >7. These medicines were recently recommended for people with both diabetes and CKD to reduce risks for kidney disease progression or cardiovascular complications-See CDC attachment. No referral for RD and MNT for the Prevention of CKD— I think I know an RD with CKD experience 😅.

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Q8. What else should readers know? What questions would you want your dietitian peers to answer?

Rory: Registered Dietitians are the nutrition experts and are therefore the appropriate specialists for providing nutrition interventions/MNT. In addition, RDs have a broad background and training that make them key team members in the management of chronic diseases, including CKD.

Karla: How can we show insurance companies the importance of food choices/using the science of nutrition? How can we add eGFR or other micronutrient tests to annual well checks to help delay or reduce the severity of diseases will save insurance companies money rather than treat the disease at late diagnosis? For example, compare the costs of dialysis and MNT. Is it that we would need a 40+ year study? Too many variables?

Leave a comment below to let us know what you think!

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Resources

I asked these experts to share their favorite resources and recommendations where readers can learn more about these topics. Here’s what they shared.

Provider Tools

1. Kidney Disease for Health Professionals (NIDDK)

2. CKD in the United States, 2023 (CDC)

3. MNTWorks Toolkit (eatright Pro)🔒

Research

1. Medical Nutrition Therapy for Patients with Non-Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions (JAND, 2018)

2. Medical Nutrition Therapy Access in CKD: A Cross-sectional Survey of Patients and Providers (Kidney Medicine, 2020)

3. Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis (AJKD, 2011)

4. Karla’s list of 40+ studies across kidney nutrition topics (See list here)

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Discussion

Here are a few insights and perspective from around the community shared on my LinkedIn thread last week. Subscribe to Signals to join the discussion in the comments below.

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Sara Eve Schaeffer, MBA, MA, RD: “And don’t forget that MNT is covered post-transplant!”

Jessica Panetta, MA, RD: “Promotion of MNT is great. Conversion is better. 1) Physicians need to know about MNT + actively refer to RDs. 2) Individuals referred to RDs then need make the appointment, show up, and act on the recommended interventions. This is a multifaceted issue that could warrant an entire article! To connect it back to the original message- awareness and education are crucial catalysts for change here, in my opinion.”

Rebecca Baranoff, MSW, CCA, CRC, CPC: “When I worked in dialysis it seemed MNT was used only in short studies and the margins in which a patient qualified for the study were really narrow. It’s possible though that the new guidelines have set different margins for this treatment. The other thing that happened was the patients that were given MNT PO were older patients with cognitive deficits. So how do we educate patients so they really understand why they are getting this therapy?”

Bethany Keith, MS, RDN, LD, CNSC: “I believe that connecting CKD patients with RDs goes hand in hand with early identification of CKD. Many people don’t know that they have kidney disease until stage 3 or later, when they could have been make dietary changes earlier on to help slow the progression of CKD. Access to renal dietitians is slowly increasing due to the rise of telehealth in the post pandemic world. Now many people can talk to a renal dietitian from the comfort of their own home, however people in rural areas may not have access to internet or be aware of telehealth options. I think the potential interventions that Jimenez and colleagues outlined are spot on!”

Rory Caswell Pace, MPH, RD, CSR, FAND, FNKF: “Dietitians ABSOLUTELY have the ability to impact patient activation. Because MNT includes engaged counseling to facilitate health-related behavior change, there is significant opportunity to increase patients'/clients' health literacy and self-care skills, which are captured in the PAM.”

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Thanks for tuning in this week. Please share this strong dose of optimism with your corner of the Kidneyverse — and consider subscribing today!

1. Medical Nutrition Therapy — CDC DSMES Toolkit

2. Feasibility and impact of ketogenic dietary interventions in polycystic kidney disease: KETO-ADPKD-a randomized controlled trial. (Cell Rep Med, 2023)