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Implementing the “Advancing American Kidney Health Initiative” by Leveraging Nutritional and Dietary Management of Kidney Patients

      This month’s editorial of the Journal of Renal Nutrition (JREN) is devoted to both the recent presidential Executive Order (EO) on kidney health initiatives and the articles published in this issue of JREN. On July 10, 2019, the US government took a series of actions to advance kidney care in the nation including a presidential EO entitled, “Advancing American Kidney Health Initiative.”
      The White House
      Executive Order on Advancing American Kidney Health. TheWhiteHousegov.
      The EO’s intention is to prevent kidney failure through better diagnosis and treatment as well as better incentives for preventative kidney care. To achieve the goal of transforming chronic kidney disease (CKD) prevention and management and to better increase education and awareness to this end, 3 broad goals are proposed for delivering the new policies: (1) reducing the number of Americans developing end-stage renal disease (ESRD) by 25% by 2030 through improved efforts to prevent, detect, and slow the progression of kidney disease; (2) aim for 80% of new American ESRD patients receiving dialysis in the home or receiving a transplant by 2025; and (3) aim to double the number of kidneys available for transplant by 2030.
      The Renal Nutrition community enthusiastically welcomes this timely EO and reminds the government and all stakeholders that in the midst of these positive developments, it is important to reiterate the critical role of nutritional and dietary interventions to achieve and enhance these goals in persons with or at risk for kidney disease. As discussed in our previous commentaries,
      • Moore L.W.
      • Kalantar-Zadeh K.
      Opportunities for renal nutrition and metabolism at the dawn of 2020s: an inauguration message from the new JREN editors-in-chief.
      • Kalantar-Zadeh K.
      • Moore L.W.
      Does kidney longevity mean healthy vegan food and less meat or is any low-protein diet good enough?.
      • Kalantar-Zadeh K.
      • Moore L.W.
      Why the nutritional management of acute versus chronic kidney disease should differ.
      under the context of secondary prevention in persons with earlier signs of CKD including microalbuminuria or renal hyperfiltration, for both persons with native kidneys and kidney transplant recipients, eating low-sodium (<2.3 g/day) and low-protein (0.6-0.8 g/kg/day) foods should be the cornerstone of nonpharmacologic approaches. These measures can also result in slowing CKD progression and avoiding or delaying ESRD transition.
      • Kalantar-Zadeh K.
      • Fouque D.
      Nutritional management of chronic kidney disease.
      For the tertiary prevention of CKD, i.e., improving patient longevity and managing comorbidities in those with advanced CKD, nutritional interventions play a critical role and should be reinforced.
      • Rhee C.M.
      • Ahmadi S.F.
      • Kovesdy C.P.
      • Kalantar-Zadeh K.
      Low-protein diet for conservative management of chronic kidney disease: a systematic review and meta-analysis of controlled trials.
      • Kistler B.M.
      • Benner D.
      • Burrowes J.D.
      • et al.
      Eating during hemodialysis treatment: a consensus statement from the International Society of Renal Nutrition and Metabolism.
      Nutritional interventions are also important strategies for the primary prevention of kidney disease, given that obesity, diabetes, and hypertension, the 3 main risk factors of de novo CKD, are amenable to nutritional and dietary interventions.
      • Ko G.J.
      • Kalantar-Zadeh K.
      • Goldstein-Fuchs J.
      • Rhee C.M.
      Dietary approaches in the management of diabetic patients with kidney disease.
      Emerging data suggest that Americans eat increasingly more protein (1.3-1.4 g/kg/day) than the Recommended Dietary Allowance (0.8 g/kg/day)
      • Moore L.W.
      • Byham-Gray L.D.
      • Scott Parrott J.
      • et al.
      The mean dietary protein intake at different stages of chronic kidney disease is higher than current guidelines.
      and that this high protein intake, by virtue of causing increased intraglomerular pressure with resultant glomerular hyperfiltration, may affect kidney health over time across populations at risk for kidney disease.
      • Kalantar-Zadeh K.
      • Moore L.W.
      Why the nutritional management of acute versus chronic kidney disease should differ.
      • Ko G.J.
      • Obi Y.
      • Tortorici A.R.
      • Kalantar-Zadeh K.
      Dietary protein intake and chronic kidney disease.
      Hence, a low-sodium with low-protein lifestyle should be the general recommendation in our plight for kidney health, and higher intake of plant-based foods with high fibers along with complex carbohydrates with resistant starch (see below) and monounsaturated and polyunsaturated fats should be encouraged.
      • Kalantar-Zadeh K.
      • Moore L.W.
      Does kidney longevity mean healthy vegan food and less meat or is any low-protein diet good enough?.
      • Joshi S.
      • Shah S.
      • Kalantar-Zadeh K.
      Adequacy of plant-based proteins in chronic kidney disease.
      Among persons at higher risk of CKD are the kidney transplant donors with a solitary kidney, in whom higher intake of sodium (>4 g/day) and protein (>1 g/kg/day) and higher body mass index (>30 kg/m2) should be avoided in an effort to achieve the greatest kidney longevity and rejuvenation.
      • Tantisattamo E.
      • Dafoe D.C.
      • Reddy U.G.
      • et al.
      Current management of acquired solitary kidney.
      Given that dietitians are the real-world executers of these goals, the President’s EO should direct the Center for Medicare and Medicaid Services to launch innovative and effective payment models intended to incentivize providers to support these goals, including practicing dietitians. The overhaul is necessary for dietitian involvement to more effectively identify and treat at-risk populations earlier in CKD progression as well as those with moderate to advanced CKD and kidney transplanted patients. This model will be in sharp contrast to the current Center for Medicare and Medicaid Services payment system whereby the renal dietitians’ focus of work is in the dialysis units, while patients at risk of CKD or those with early to advanced CKD have difficulty obtaining coverage for dietary counseling for kidney health. Of special importance are children and young adults, in whom the risk factors for CKD should be effectively identified and addressed by ensuring a healthy lifestyle and healthy diet. Also important is the role of educators to emphasize the important skill sets required for training dietitians in renal specialties and the provision of Medical Nutrition Therapy in varied settings outside the dialysis units.
      • Moore L.W.
      The renal dietitian in the clinic—medical nutrition therapy.
      A few years ago, JREN published the Standards of Practice and Standards of Professional Performance for dietitians in nephrology settings
      • Kent P.S.
      • McCarthy M.P.
      • Burrowes J.D.
      • et al.
      Academy of Nutrition and Dietetics and National Kidney Foundation: revised 2014 standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in nephrology nutrition.
      ; an update to these standards will be published in the near future in JREN.
      In this issue of the JREN, Martin-del-Campo et al.
      • Martin-Del-Campo F.
      • Batis-Ruvalcaba C.
      • Ordaz-Medina S.M.
      • et al.
      Frequency and risk factors of kidney alterations in children and adolescents who are overweight and obese in a primary health-care setting.
      examined the association of obesity with kidney disease in 172 children and adolescents and found that renal hyperfiltration (defined as estimated glomerular filtration rate >170 mL/min/1.73 m2) and microalbuminuria were present in children and adolescents with overweight and obesity, whereas those considered at normal weight exhibited no kidney alterations. Hence, better nutritional management of children to prevent or correct obesity may have an impact on overall kidney health across the population.
      In another article of this JREN issue by Song et al.,
      • Song A.Y.
      • Crews D.C.
      • Ephraim P.L.
      • et al.
      Sociodemographic and kidney disease correlates of nutrient intakes among urban African Americans with uncontrolled hypertension.
      the associations of sociodemographic factors with food intake and markers of kidney disease were examined in 159 African Americans from the Baltimore, Maryland area with uncontrolled hypertension at high risk of kidney disease. Compared to the Institute of Medicine’s recommendations, the African Americans participating in this study had lower intakes of magnesium, fiber, and potassium but higher vitamin C intakes. Among female participants, sociodemographic factors associated with lower intake of the 4 nutrients were older age, obesity, lower health numeracy, and lesser educational attainment. Below-median intake of these micronutrients was associated with 2.9- to 3.6-fold higher likelihood of microalbuminuria, a key biomarker of kidney damage. The investigators concluded that African Americans with uncontrolled hypertension may have low intakes of important nutrients for kidney health that could result in higher CKD risk. They suggest that tailored dietary interventions for African Americans at high risk for CKD should be explored.
      • Song A.Y.
      • Crews D.C.
      • Ephraim P.L.
      • et al.
      Sociodemographic and kidney disease correlates of nutrient intakes among urban African Americans with uncontrolled hypertension.
      In this issue of JREN, Yong et al
      • Yong K.
      • Mori T.
      • Chew G.
      • et al.
      The effects of OMEGA-3 fatty acid supplementation upon interleukin-12 and interleukin-18 in chronic kidney disease patients.
      present the results of their randomized placebo-controlled trial in 73 nondiabetic patients with Stage 3-4 CKD to examine the effects of 4 g/day Omega-3 fatty acids supplementation on inflammatory markers including serum interleukin (IL)-12, IL-18, and C-reactive protein. After the dietary intervention, the magnitude of increase in serum IL-18 was significantly less in the treatment group compared to placebo, although there were no apparent effects on other markers of inflammation.
      Although the 3 aforementioned studies by Martin-del-Campo et al.
      • Martin-Del-Campo F.
      • Batis-Ruvalcaba C.
      • Ordaz-Medina S.M.
      • et al.
      Frequency and risk factors of kidney alterations in children and adolescents who are overweight and obese in a primary health-care setting.
      , Song et al.,
      • Song A.Y.
      • Crews D.C.
      • Ephraim P.L.
      • et al.
      Sociodemographic and kidney disease correlates of nutrient intakes among urban African Americans with uncontrolled hypertension.
      and Yong et al.
      • Yong K.
      • Mori T.
      • Chew G.
      • et al.
      The effects of OMEGA-3 fatty acid supplementation upon interleukin-12 and interleukin-18 in chronic kidney disease patients.
      imply the potential impact of nutritional status including certain nutrient intakes on CKD risk and on disease progression, i.e., primary and secondary prevention of CKD, in the nested case-control study by Abbasi et al.,
      • Abbasi M.
      • Daneshpour M.S.
      • Hedayati M.
      • Mottaghi A.
      • Pourvali K.
      • Azizi F.
      Dietary total antioxidant capacity and the risk of chronic kidney disease in patients with type 2 diabetes: a nested case-control study in the Tehran Lipid Glucose Study.
      also published in this issue of JREN, there was no significant association of total antioxidant capacity of the food or total dietary energy intake with prevalence of CKD in persons with type 2 diabetes. It is possible that dietary factors relevant to patients with diabetes and no CKD, such as higher dietary energy intake, are less relevant to patients with CKD and diabetes, and that dietary protein intake is a more relevant dietary target as shown recently, although the latter was not examined in this study.
      • Abbasi M.
      • Daneshpour M.S.
      • Hedayati M.
      • Mottaghi A.
      • Pourvali K.
      • Azizi F.
      Dietary total antioxidant capacity and the risk of chronic kidney disease in patients with type 2 diabetes: a nested case-control study in the Tehran Lipid Glucose Study.
      Of note, a recent study by Malhotra et al.
      • Malhotra R.
      • Lipworth L.
      • Cavanaugh K.L.
      • et al.
      Protein intake and long-term change in glomerular filtration rate in the Jackson Heart Study.
      showed that among African Americans with diabetes, a higher dietary protein intake was associated with a faster rate of CKD progression.
      Eating “resistant starch” is among increasingly popular dietary approaches these days, and this may have potential utility for the management of diabetic kidney disease. Starches are long chains of carbohydrate moieties that are readily digested leading to higher glycemic burden, whereas resistant starch is much less digestible, and, hence, may improve glycemic status and have more favorable effects on gut microbiota similar to soluble fibers. Beans and lentils are rich in resistant starch, as are whole grains including barley and oats. In this issue of JREN, Meng et al.,
      • Meng Y.
      • Bai H.
      • Yu Q.
      • et al.
      High-resistant starch, low-protein flour intervention on patients with early type 2 diabetic nephropathy: a randomized trial.
      in a randomized, comparative, open-label trial, examined the effect of a low-protein flour with high-resistant starch in 75 adult patients with early type 2 diabetic nephropathy over 12 weeks. The 38 control subjects followed a low protein diet with a common staple, whereas the 37 intervention subjects received 50 g of high-resistant starch, low-protein flour instead of a common staple of equal quality at lunch and dinner each day. The latter intervention resulted in a significant reduction in fasting blood sugar, hemoglobin A1c, total cholesterol, triglycerides, and uric acid levels, while serum superoxide dismutase level increased, although IL-6 and tumor necrosis factor α concentrations did not change.
      • Meng Y.
      • Bai H.
      • Yu Q.
      • et al.
      High-resistant starch, low-protein flour intervention on patients with early type 2 diabetic nephropathy: a randomized trial.
      Despite the short-term (12-week) length of the study, the observed effects are promising and suggest that the effect of low-protein diet on secondary prevention of CKD can be further enhanced by adding resistant starch in lieu of mainstream carbohydrates.
      Other articles in this issue of JREN include the following: Samaan et al.
      • Samaan F.
      • Carvalho A.B.
      • Pillar R.
      • et al.
      The effect of long-term cholecalciferol supplementation on vascular calcification in chronic kidney disease patients with hypovitaminosis D.
      conducted a randomized controlled study over 18 months in 80 patients with CKD Stages 3-4 and mild to moderate hypovitaminosis D (serum 25-OH-D level <30 but >15 ng/mL) with cholecalciferol and reported no change in vascular calcification progression. On the other hand, in another randomized controlled trial in 32 dialysis patients with hypovitaminosis D by de Carvalho et al.,
      • de Carvalho J.T.G.
      • Schneider M.
      • Cuppari L.
      • Grabulosa C.C.
      • Cendoroglo M.
      • Dalboni M.A.
      Cholecalciferol supplementation did not change interleukin-7 and B cell-activating factor levels and CD95 expression in B lymphocytes in patients on dialysis: a randomized pilot-controlled trial.
      cholecalciferol supplementation did not exhibit detectable changes in IL-7 and B cell–activating factor levels or CD95 expression in B lymphocytes. Spatola et al.
      • Spatola L.
      • Finazzi S.
      • Santostasi S.
      • Angelini C.
      • Badalamenti S.
      Geriatric nutritional risk index is predictive of subjective global assessment and dialysis malnutrition scores in elderly patients on hemodialysis.
      compared subjective nutritional tools including the Subjective Global Assessment and Dialysis-Malnutrition Score with an objective malnutrition evaluation tool known as “Geriatric Nutritional Risk Index” in 71 elderly hemodialysis patients and found that Geriatric Nutritional Risk Index is a reliable nutritional tool predictive of Subjective Global Assessment and Dialysis-Malnutrition Score, pointing out a relationship between objective and subjective malnutrition indices in this patient group. Kendrick et al.
      • Kendrick J.
      • Parameswaran V.
      • Ficociello L.H.
      • et al.
      One-year historical cohort study of the phosphate binder sucroferric oxyhydroxide in patients on maintenance hemodialysis.
      examined real-world data of phosphorus management in 530 hemodialysis patients and found that switching from non-iron-based binders to sucroferric oxyhydroxide resulted in a 2-fold higher likelihood of achieving target phosphorus levels while halving daily pill burden of phosphorus binding therapy. The investigators also noted increases in serum phosphorus-attuned albumin and dietary protein intake suggesting improved nutritional status as a result of more effective phosphorus therapy that would allow less dietary restrictions.
      • Kendrick J.
      • Parameswaran V.
      • Ficociello L.H.
      • et al.
      One-year historical cohort study of the phosphate binder sucroferric oxyhydroxide in patients on maintenance hemodialysis.
      Yeh et al.
      • Yeh S.C.
      • Lin Y.C.
      • Hong Y.C.
      • Hsu C.C.
      • Lin Y.C.
      • Wu M.S.
      Different effects of iron indices on mortality in patients with autosomal dominant polycystic kidney disease after long-term hemodialysis: a nationwide population-based study.
      compared the mortality predictability of iron indices in 1,346 hemodialysis patients with polycystic kidney disease (PKD) and 82,873 without PKD and found that the U-shaped curve of mortality against ferritin and iron saturation levels was not observed in patients with PKD, which was in contrast to those with PKD. They concluded that iron indices exhibit different associations with mortality when comparing hemodialysis patients with versus without PKD.
      • Yeh S.C.
      • Lin Y.C.
      • Hong Y.C.
      • Hsu C.C.
      • Lin Y.C.
      • Wu M.S.
      Different effects of iron indices on mortality in patients with autosomal dominant polycystic kidney disease after long-term hemodialysis: a nationwide population-based study.
      Finally, in a study to quantify how dialysis dietitians spend their time in the dialysis units, Hand et al.
      • Hand R.K.
      • Albert J.M.
      • Sehgal A.R.
      Quantifying the time used for renal dietitian's responsibilities: a pilot study.
      reported that only 25% of dietitians’ time was available for direct patient care, which is much less than that reported in previous studies and may not be sufficient to improve the nutritional status of dialysis patients.
      In addition to the aforementioned original research papers, in this issue of JREN there is an exhaustive review of the literature by Anderson et al.
      • Anderson J.
      • Peterson K.
      • Bourne D.
      • Boundy E.
      Effectiveness of intradialytic parenteral nutrition in treating protein-energy wasting in hemodialysis: a rapid systematic review.
      on the effectiveness of intradialytic parenteral nutrition (IDPN) in treating protein-energy wasting in hemodialysis patients. The authors have concluded that IDPN is a reasonable treatment option for patients who fail to respond to protein-energy wasting therapy or cannot receive recommended treatments, although they suggest that the broad usage of IDPN before recommended treatment options may not be warranted. As to what level of serum albumin (e.g., <3.5 vs. <3.0 g/dL, via bromocresol green method) and over which period of time (1 vs. 3 months or longer) and under which circumstances (exhausting oral nutritional supplement therapy or pharmacologic corrections first) are required as the clinical indicators to start IDPN, the jury is still out. We expect that a constructive discussion on the utility of IDPN to be continued on this and other topics, hoping that JREN can provide the most effective platform for such productive clinical debates and scientific discoveries.
      • Moore L.W.
      • Kalantar-Zadeh K.
      Opportunities for renal nutrition and metabolism at the dawn of 2020s: an inauguration message from the new JREN editors-in-chief.

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