Renal Dietitians' Perceptions of Roles and Responsibilities in Outpatient Dialysis Facilities

Dietitians' practices in dialysis units in Brazil: nutritional assessment and intervention

INTRODUCTION

The importance of dietitians in dialysis units is indisputable and mandatory in Brazil, but little is known about the practices adopted by these professionals.

OBJECTIVE

To know practices adopted in routine nutritional care, focusing on nutritional assessment tools and treatment strategies for people at risk or diagnosed with malnutrition.

METHODOLOGY

Electronic questionnaire disseminated on social media and messaging applications. It included questions that covered dietitians' demographic and occupational profile characteristics and of the dialysis unit, use and frequency of nutritional assessment tools, nutritional intervention strategies in cases of risk or diagnosis of malnutrition, prescription and access to oral supplements.

RESULTS

Twenty four percent of the Brazilian dialysis units (n = 207) responded electronically. The most used nutritional assessment tools with or without a pre-established frequency were dietary surveys (96%) and Subjective Global Assessment (83%). The strategies in cases of risk or presence of malnutrition used most frequently (almost always/always) were instructions to increase energy and protein intake from foods (97%), and increasing the frequency of visits (88%). The frequency of prescribing commercial supplements with standard and specialized formulas was quite similar. The availability of dietary supplements by the public healthcare system to patients varied between regions.

CONCLUSION

Most dietitians use various nutritional assessment tools and intervention strategies in cases of risk or malnutrition; however, the frequency of use of such tools and strategies varied substantially.

Workforce needs and estimated costs/savings for nutrition care in chronic kidney disease-stage 3 through maintenance dialysis

The role of nutrition in chronic kidney disease (CKD) is well known. However, controversies, misconceptions, and gaps in the literature exist regarding the workforce required to provide nutrition care in CKD. This paper reviews the existing literature on this topic, focusing primarily on the United States. Topics covered in this review include the qualifications and services of the registered dietitian nutritionist (RDN), to which specific patients nutrition care should be provided in CKD and on dialysis, barriers to the utilization of nutrition services, the quantity of nutrition care needed to improve patient outcomes, and the risks of provider burnout. Controversies include whether more staffing is associated with better care and the best measures of staffing. The topics are supported with estimations for the economic impact and practicality of workforce decisions.

Academy of Nutrition and Dietetics Commentary on the Phosphorus Recommendation in the KDOQI Clinical Practice Guidelines for Nutrition in CKD: 2020 Update

The Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease: 2020 Update recommends adjusting dietary phosphorus to maintain a serum phosphate goal for hemodialysis patients in the normal range (0.81 to 1.45 mmol/L [2.5 to 4.5 mg/dL]). This is lower than the serum phosphate goal used by many dialysis centers (0.97 to 1.78 mmol/L [3.0 and 5.5 mg/dL]). Although context and clinical judgment must always be considered when providing individualized care to patients, a guideline implementation study conducted from December 2020 to December 2022 found that, based on their documentation, registered dietitian nutritionists from two national dialysis chains are almost universally using dialysis center goals instead of the lower phosphate goal recommended by the guideline. This commentary discusses the possible barriers to implementing the Kidney Disease Outcomes Quality Initiative 2020 nutrition guideline's phosphorus recommendation and proposes a systems level approach to promote and support adoption of the recommendation. Calls to action for potential changes in clinician practices, organizational/institutional culture, and government regulations are put forth.

A Novel Clinical Tool for the Management of Taste Changes in Patients With Chronic Kidney Disease: The Chronic Kidney Disease Taste Plate

Taste alteration is a common, but poorly understood, symptom in end-stage kidney disease. The pathophysiology of taste alteration is complex; to date, management has been largely empirical. As our understanding of pathophysiology grows so does the evidence base for its management. This article introduces a clinical tool-the CKD Taste Plate-to assist clinicians in directing management to the underlying pathophysiology of taste alterations in chronic kidney disease.

Dietary intake in adults on hemodialysis compared with guideline recommendations

Background

Clinical practice guidelines of dietary management are designed to promote a balanced diet and maintain health in patients undergoing haemodialysis but they may not reflect patients’ preferences. We aimed to investigate the consistency between the dietary intake of patients on maintenance haemodialysis and guideline recommendations.

Methods

Cross-sectional analysis of the DIET-HD study, which included 6,906 adults undergoing haemodialysis in 10 European countries. Dietary intake was determined using the Global Allergy and Asthma European Network (GA²LEN) Food Frequency Questionnaire (FFQ), and compared with the European Best Practice Guidelines. Consistency with guidelines was defined as achieving the minimum daily recommended intake for energy (≥ 30 kcal/kg) and protein (≥ 1.1 g/kg), and not exceeding the maximum recommended daily intake for phosphate (≤ 1000 mg), potassium (≤ 2730 mg), sodium (≤ 2300 mg) and calcium (≤ 800 mg).

Results

Overall, patients’ dietary intakes of phosphate and potassium were infrequently consistent with guidelines (consistent in 25% and 25% of patients, respectively). Almost half of the patients reported that energy (45%) and calcium intake (53%) was consistent with the guidelines, while the recommended intake of sodium and protein was consistent in 85% and 67% of patients, respectively. Results were similar across all participating countries. Intake was consistent with all six guideline recommendations in only 1% of patients.

Conclusion

Patients on maintenance haemodialysis usually have a dietary intake which is inconsistent with current recommendations, especially for phosphate and potassium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-020-00962-3.

Effect of Phosphate-Specific Diet Therapy on Phosphate Levels in Adults Undergoing Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Hyperphosphatemia is a persistent problem in individuals undergoing maintenance hemodialysis, which may contribute to vascular and bone complications. In some dialysis centers, dietitians work with patients to help them manage serum phosphate. Given the regularity of hyperphosphatemia in this population and constraints on kidney dietitian time, the authors aimed to evaluate the evidence for this practice.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

There was a systematic review and meta-analysis of clinical trials. MEDLINE, Embase, CINAHL, Web of Science, Cochrane Central Register of Controlled Trials, and other databases were searched for controlled trials published from January 2000 until November 2019 in the English language. Included studies were required to examine the effect of phosphate-specific diet therapy provided by a dietitian on serum phosphate in individuals on hemodialysis. Risk of bias and certainty of evidence were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method.

RESULTS

Of the 8054 titles/abstracts identified, 168 articles were reviewed, and 12 clinical trials (11 randomized, one nonrandomized) were included. Diet therapy reduced serum phosphate compared with controls in all studies, reaching statistical significance in eight studies, although overall certainty of evidence was low, primarily due to randomization issues and deviations from protocol. Monthly diet therapy (20-30 minutes) significantly lowered serum phosphate in patients with persistent hyperphosphatemia for 4-6 months, without compromising nutrition status (mean difference, -0.87 mg/dl; 95% confidence interval, -1.40 to -0.33 mg/dl), but appeared unlikely to maintain these effects if discontinued. Unfortunately, trials were too varied in design, setting, and approach to appropriately pool in meta-analysis, and were too limited in number to evaluate the timing, dose, and strategy of phosphate-specific diet therapy.

CONCLUSIONS

There is low-quality evidence that monthly diet therapy by a dietitian appears to be a safe and efficacious treatment for persistent hyperphosphatemia in patients on HD.

Registered Dietitian Staffing in Dialysis: Impact on Quality Ratings in Mandate and Nonmandate States

OBJECTIVE

Texas is the only state to mandate a patient to full-time equivalent (FTE) registered dietitian (RD) ratio (<125 patients:FTE RD) in dialysis. Little research exists about the relationship between patient:FTE RD ratio and quality. Our objectives were to a) examine the effect of the mandate on patient:FTE RD ratios in Texas facilities compared to similar nonmandated facilities and b) examine the association between patient:FTE RD ratio and the patient rating of staff quality or star rating of the facility.

DESIGN AND METHODS

Using data from Dialysis Facility Annual Reports, we excluded facilities with less than 125 patients and matched based on region, chain/profit status, and number of patients, pairing each Texas facility with 2 non-Texas facilities. T-tests for difference of means and chi-square tests were performed to compare facility groups characteristics and assess mandate impact. We used correlation between patient:FTE RD ratio and staff quality linearized score, and ANOVA to compare patient:FTE RD ratios between the star rating levels.

RESULTS

The patient:FTE RD ratio was higher in non-Texas than Texas facilities (111.84 ± 40.70 vs 90.80 ± 24.02, P < .01). The Pearson correlation between patient:FTE RD ratio and linearized score rating of the dialysis center staff was essentially nonexistent (r = -0.046). We found a trend of higher patient:FTE RD ratios in facilities with lower star ratings for quality and staff but no statistical significance.

CONCLUSION

The mandate effectively lowered the patient:FTE RD ratio in Texas dialysis facilities with over 125 patients, indicating that states considering such a mandate may benefit from implementing it. We found no association between patient:FTE RD staffing and quality, either objectively or via patient assessment. Further research should examine whether dialysis facilities are trending toward smaller patient sizes to circumvent staffing mandates and examine the relationship between other professions' staffing ratios and quality.

A Clustered Randomized Trial Informing Patients on Dialysis About Their Ability to Donate Organs and Tissues

INTRODUCTION

The transplant waiting list exceeds the number of organs available. One means of increasing the organ pool is to broaden potential donors to include those with chronic diseases.

RESEARCH QUESTIONS

The study tested the effectiveness of using peer mentors to encourage individuals on dialysis to enroll on an organ donor registry.

DESIGN

Dialysis units were pair-matched by size and racial composition and then randomized to one of 2 interventions: meetings with a peer mentor (experimental intervention) or organ donation mailings (control). Peer mentors were trained to discuss organ donation with individuals on dialysis during in-person meetings at dialysis units. The primary outcome was verified registration in the state's donor registry.

RESULTS

After adjusting for age, gender, race, income, and education and accounting for correlation within the dialysis center, there was a significant intervention effect. Among individuals in the intervention group, the odds of enrolling (verified) on the donor registry were 2.52 times higher than those in the control group.

DISCUSSION

The use of peer mentors to discuss donating organs after death with individuals on dialysis can increase enrollment on a donor registry. Dispelling myths about chronic illness and donation can counter widely held misconceptions and help persons make an informed choice about end-of-life decisions and present an opportunity to increase the number of organs and tissues available for transplant.

Dietetics Program Directors in the United States Support Teaching Vegetarian and Vegan Nutrition and Half Connect Vegetarian and Vegan Diets to Environmental Impact

Registered Dietitian Nutritionists (RDNs) are clinicians trained in the application of food, nutrition, and dietetics. Vegetarians and vegans have a lower risk of many nutrition-related chronic diseases that are epidemic while vegetarian and vegan diets are associated with reduced environmental impact. Despite this strong diet-disease and diet-environment connection, it is not known if dietetics students are taught the principles of vegetarian and vegan nutrition. The overarching goal of our study was to investigate curricular practices in accredited dietetics training programs in the United States (U.S.) including (1) the prevalence and perceived importance of vegetarian and vegan nutrition instruction and (2) if program directors connect vegetarian and vegan diets to climate change mitigation and resource conservation. Primary data were collected by way of a cross-sectional, Internet-based survey. All Accreditation Council for Education in Nutrition and Dietetics (ACEND) program directors in the U.S. (N = 574) were sent a 37-question survey and invited to participate in the study. Outcome measures included the prevalence of vegetarian and vegan nutrition instruction, quantifying if relationships exist among variables, and the frequency of connecting vegetarian and vegan diets to environmental impact. Descriptive and inferential statistics were utilized. Respondents (n = 205) indicated that over 51% of programs teach vegetarian nutrition while 49% teach vegan nutrition. There were significant differences between program type and the prevalence of vegetarian (p = 0.00005) and vegan (p = 0.00005) nutrition instruction. Over 90% of program directors believe that vegetarian and vegan nutrition should be taught. Over 50% of programs identify the connection between vegetarian and vegan diets in climate change mitigation and resource conservation. Most ACEND program directors believe vegetarian and vegan nutrition should be taught and half connect diet to environmental concern. Nevertheless, there is a discrepancy between beliefs and practice behaviors. These results suggest the need for increased collaboration and the use of novel techniques that better incorporate vegan and vegetarian nutrition throughout dietetics education.

Renal Dietitians' Perceptions of the Value of Subjective Global Assessment: A Mixed Methods Study

OBJECTIVE

The objective of this study is to assess how renal registered dietitians (RDs) in Canada perceive the value of Subjective Global Assessment (SGA) to assess protein-energy wasting for clients with chronic kidney disease.

DESIGN AND METHODS

A sequential exploratory mixed method approach included 2 focus groups (n = 6 and 8) and a national survey (n = 54). Two online focus groups were conducted 1 month apart followed by an online survey. Participants included renal RDs working with Stage 5 chronic kidney disease (dialysis and non-dialysis) patients.

RESULTS

Five main themes (consistency, organizational/environment, confidence, interpretation, and education) emerged. Renal RDs support using a tool to provide a standardized process for nutrition assessment and feel SGA is an effective educational tool; however, barriers such as time, privacy, confidence in the tool, as well as ability to perform physical assessment, interpretation, and subjectivity limit the use of SGA. Renal RDs feel that it is important to examine nutrition interventions in conjunction with SGA results.

CONCLUSION

The main results of the study describing the limitations to the clinical use of the SGA tool revolve around RDs' time, confidence, ability to interpret the SGA tool, and how SGA is used by administration. The results support the need for educators and administrators to communicate the use of SGA results and provide education opportunities focusing on the use of validated, reliable, responsive tools to assess nutrition status as well as hands-on physical assessment. In some situations, an alternative validated version of SGA or screening tool may be appropriate.

Assessment of nutritional status in the maintenance of haemodialysis patients: a cross-sectional study from Palestine

BACKGROUND

Protein-energy wasting (PEW) is a relatively prevalent problem among adult haemodialysis patients (HDP). PEW is an important determinant of morbidity and mortality in HDP, therefore it is essential for dietitians to accurately assess malnutrition (MN) in these patients. HDP appear to be more susceptible to developing MN; however, this is not well documented. Therefore this study aimed to assess the nutritional status among HDP and to establish the factors associated with MN in these patients.

METHODS

A cross-sectional survey was carried out in Nablus, northern West Bank, in the main haemodialysis (HD) centre at the An-Najah National University Hospital. MN was detected using the malnutrition-inflammation scale (MIS), which involved four major elements: the patient's related medical history, their body mass index, a physical examination and laboratory parameters.

RESULTS

A total of 174 patients (91 male) were included in the study. Patients were aged 57.7 ± 12.8 years, and the median dialysis vintage was 3 years (interquartile range 1-5 years). HDP, especially the elderly (unstandardized coefficient β, 1.728; 95% CI, 0.700 to 2.756; P = 0.001), those with multiple comorbid diseases (unstandardized coefficient β, 1.673; 95% CI, 0.556 to 2.789; P = 0.004); those taking multiple chronic medications (unstandardized coefficient β, 1.259; 95% CI, 0.197 to 2.321; P = 0.020), or those with a long dialysis vintage (unstandardized coefficient β, 1.449; 95% CI, 0.410 to 2.487; P = 0.007), were positively associated with the MIS score in a multivariable linear regression model. Furthermore, HDP living with their family were negatively associated with the MIS score (unstandardized coefficient β, - 2.545; 95% CI, - 4.738 to - 0.352; P = 0.023).

CONCLUSIONS

The MIS score results indicate that MN is prevalent among HDP. These results demonstrate some correlations between nutritional status and patient characteristics (i.e. clinical and sociodemographic factors). Therefore these findings should help to increase the awareness of healthcare providers for interventions to enhance the nutritional status of HDP, especially those who are elderly, have multiple comorbid diseases, have multiple chronic medications, have experienced a long dialysis vintage or who live alone.

Quantifying the Time Used for Renal Dietitian's Responsibilities: A Pilot Study

OBJECTIVE

The purpose of this study was to quantify how dialysis dietitians spend their time and whether the activities that were most frequent varied based on the ratio of patient to full-time equivalent (FTE) dietitian.

METHODS

This study is a cross-sectional, observational, time-and-motion study carried out using the Work Activity Measurement by Activity Timing software/method for time recording. This study was carried out in 14 dialysis centers in and around Cleveland, Ohio. Fourteen registered dietitian nutritionists participated in this study. The mean time/experience of these nutritionists in dietetics was 26.6 ± 8.5 years. Percent of time in direct care (e.g., patient interaction) versus indirect care (e.g., documentation and plans of care, professional communication) versus other responsibilities (e.g., administrative work, education of self or others).

RESULTS

The mean number of tasks recorded per 3-hour observation session was 38.3 ± 14.0, including 18.5 ± 7.7 indirect care tasks, 7.7 ± 6.2 direct care tasks, and 9.7 ± 5.4 other tasks. The mean number of unique patients seen per observation session was 6.9 ± 5.4; the mean direct care time per patient encounter was 6.95 ± 4.05 minutes. Indirect care took the highest proportion of observed time, 56.0 ± 22.2%, followed by direct care, 24.9 ± 18.8%. Increasing the ratio of patient to FTE had a moderate negative correlation with the percent of time spent in direct patient care (r = -0.35, P = .21), but there was no relationship between the ratio of patient to FTE and direct care time per patient (r = 0.02, P = .94).

CONCLUSION

About 25% of dietitians' time was available for direct patient care. This is much less than that reported in previous studies and may not be sufficient to improve the nutritional status. Limitations of our study include a small sample size from a single region. Further work is needed to understand the balance of responsibilities among renal dietitians and their impact on patient outcomes.

Structural Equation Modeling to Explore Patient to Staff Ratios as an Explanatory Factor for Variation in Dialysis Facility Outcomes

OBJECTIVE

Patient to staff ratios vary based on facility characteristics, and therefore have been proposed as an explanatory factor for the variation in dialysis facility outcomes. This analysis tested that hypothesis.

DESIGN AND METHODS

Observational study using Dialysis Facility Report data. Reported staff numbers from the Annual Facility Survey were converted to full time equivalents (FTE). Subsequently, ratios were created for patients per FTE registered dietitian (RD), social worker, nurse, and patient care technician. Bivariate associations and structural equation modeling (SEM) were used to explore relationships between these ratios and patient outcomes: standardized mortality ratio and standardized hospitalization rate, when also considering the impact of non-modifiable facility characteristics (region, chain, profit status). Our focus was on RD staffing; therefore we also included serum phosphorus and normalized protein catabolic ratio in the model, and also conducted a sub-analysis of the 198 facilities that exceeded the KDOQI maximum of 150 patients:FTE RD.

SUBJECTS

Dialysis centers in the US with at least 30 adult patients and no pediatric patients. 4035 facilities had complete data for the proposed variables.

MAIN OUTCOME MEASURE

Standardized mortality ratio and standardized hospitalization rate were the primary outcomes.

RESULTS

The mean and standard deviation for patients per FTE staff were 90.0 ± 34.0, 88.7 ± 32.8, 17.1 ± 20.5 and 11.9 ± 7.0 for RDs, social workers, nurses, and technicians, respectively. Facility characteristics impacted staffing in bivariate analyses and SEM. The only significant paths from staffing ratio to outcomes were for patient:FTE social worker to SMR (standardized beta = -0.09, 95% CI -0.13, -0.04) and Patients:FTE RD to SHR Days (standardized beta = 0.04, 95% CI 0.001, 0.09). In the sub-analysis, there were no significant paths from staffing to outcomes.

CONCLUSIONS

This study did not provide evidence that patient per staff ratios explain variation in dialysis facility outcomes. While there are some important bivariate relationships, these disappear in more complex models. Future research should investigate the impacts of staffing ratios on individual patients, to overcome the possible ecological fallacy.