Guideline Summary NGC-8003

Guideline Title
Chronic kidney disease evidence-based nutrition practice guideline.
Bibliographic Source(s)
American Dietetic Association. Chronic kidney disease evidence-based nutrition practice guideline. Chicago (IL): American
Dietetic Association; 2010 Jun. Various p. [205 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Dietetic Association. Chronic kidney disease (non-dialysis) medical
nutrition therapy protocol. Chicago (IL): American Dietetic Association; 2002 May. Various p.

Scope
Disease/Condition(s)
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Chronickidneydisease(CKD)(non-dialysis)
Co-morbidities of CKD
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Anemia

Diabetes

Dyslipidemia

Electrolytedisorders

Obesity

Hypertension

Guideline Category
Counseling
Evaluation
Management
Prevention
Treatment
Clinical Specialty
Endocrinology
Family Practice
Geriatrics
Hematology
Internal Medicine
Nephrology
Nutrition
Intended Users
Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Patients
Physician Assistants

Advanced Practice Nurses

Dietitians
Health Care Providers
Nurses
Patients
Physician Assistants
Physicians
Students
Guideline Objective(s)
Overall Objective
To provide medical nutrition therapy (MNT) guidelines for chronic kidney disease (CKD) to prevent and treat proteinenergy malnutrition, mineral and electrolyte disorders, and to minimize the impact of other comorbidities on the
progression of kidney disease, e.g., diabetes, obesity, hypertension and disorders of lipid metabolism
Specific Objectives
Todefineevidence-based CKD nutrition recommendations for registered dietitians (RDs) that are carried out in
collaboration with other healthcare providers
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Toguidepracticedecisionsthatintegratemedical,nutritionalandbehavioralstrategies

ToreducevariationsinpracticeamongRDs

ToprovidetheRDwithdatatomakerecommendationstoadjustmedicalnutritiontherapy(MNT)orrecommend
other therapies to achieve desired outcomes
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Todevelopguidelinesforinterventionsthathavemeasurableclinicaloutcomes

Todefinethehighestqualityofcarewithincostconstraintsofthecurrenthealthcareenvironment

Target Population
Adults diagnosed with chronic kidney disease
Interventions and Practices Considered
Evaluation
1.Referraltoaregistereddietitian
2.Nutritionassessment
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Clienthistoryincludingmedical,social,andpersonalhistoryandhistoryofmedicationsandsupplements

Biochemicaldataandrelevantlaboratoryvalues

Anthropometricmeasurementsincludingheight,weight,bodymassindex(BMI),waistcircumference,andweight
change rate
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Nutritionhistoryincludingfoodintake,physicalactivityandexercise,foodavailability,psychosocialand
economic issues impacting nutrition therapy, and consideration of co-morbid conditions
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Physicalexaminationfindings

Management/Treatment
1.Individualizedprescriptionbasedon:
Nutritioninterventionsuchasintakeofprotein,energy,phosphorus,sodium,calciumandvitaminDand
multivitamin supplements, fish oil/omega-3 fatty acids, iron supplementation
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Physicalactivityinterventions

Behavioralinterventions

Managementofco-morbidities such as anemia, hyperglycemia, dyslipidemia, and hypertension

2.Coordinationofnutritioncare
3.Monitoringofprogress
Major Outcomes Considered
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Nutritionalstatus(weight,muscleandfatstores,serumalbumin)

Glomerularfiltrationrates(GFRs)

Bloodpressurelevels

Progressionofkidneydisease

Serumphosphoruslevels

Bloodglucoselevels

Methodology
Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Bloodglucoselevels

Methodology
Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
General Methods for Collecting/Selecting the Evidence
The following list provides an overview of the steps which the American Dietetic Association (ADA) evidence analysis
team goes through to identify research through database searches.
1.Planthesearchstrategytoidentifythe"currentbestevidence"relevanttothequestion.Theplanforidentification
and inclusion of articles and reports should be systematic and reproducible, not haphazard. Write out the original
search strategy and document adjustments to the strategy if they occur. Allow for several iterations of searches.
2.Listinclusionandexclusioncriteria.Theworkgroupwilldefinetheinclusionandexclusioncriteria.Thesecriteria
will be used in defining the search strategy and for filtering the identified research reports. ADA uses only peerreviewed research; that is, articles accepted for evidence analysis must be peer-reviewed and published in a juried
publication. Additionally, ADA only uses human subjects in its research and does not include animal studies in its
evidence analysis.
3.Identifysearchwords.Duringtheprocessofconsideringoutcomes,interventions,nutritiondiagnoses,and
assessments, the work group may have identified a number of specific terms or factors that were important, but were
not included in the actual question. These terms can be used as additional search terms to help identify relevant
pieces of research. Both text word search and keyword search using Medical Subject Headings (MeSH) definitions may
be used.
4.Identifydatabasestosearch.PubMed,Medline,CINAHL,EMBASE,Cochrane,Agricola,DARE,TRIP,AHRQandERIC
are some common databases for clinical nutritional research. Note that search terms can vary depending on the
database.
5.Conductthesearch.Dependingonthenumberandtypeofsourcesfoundintheinitialsearch,adjustmentsmight
have to be made in the search strategy and to inclusion/exclusion criteria, and additional searches run. Changes to
the search plan should be recorded for future reference. Document the number of sources identified in each search.
6.Reviewtitlesandabstracts.Atthispoint,filteringprocedureisusedtodeterminewhetheraresearcharticle
matches the inclusion criteria and is relevant to the work group's questions. Typically, the lead analyst, along with a
member of the expert workgroup, first reviews the citations and abstracts to filter out reports that are not applicable
to the question. If a determination cannot be made based on the citation and abstract, then the full text of the article
is obtained for review.
7.Gatherallremainingarticlesandreports.Obtainpaperorelectroniccopiesofresearcharticlesthatremainonthe
list following the citation and abstract review. If there are less than six citations, it could mean that the search was
too specific to identify relevant research or that research has not been done on this topic. A broadened search should
be tried. When there is a long list of citations, ascertain whether it includes articles that are tangential to the
question or address the question in only a general way. In this case a more focused search strategy may be
necessary.
Specific Methods for This Guideline
The recommendations in the guideline were based on a systematic review of the literature. Searches of PubMed,
CENTRAL, and CINAHL and hand searches of other relevant literature were performed on the following topics:
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Medicalnutritiontherapyanddietitianintervention

Energyneeds

Proteinneeds

Chronickidneydisease(CKD)-bone mineral disorder

Anemia

Diabetes

Obesity

Hypertension

Disordersoflipidmetabolism

Physicalactivity

Fishoiltherapy

Each evidence analysis topic has a link to supporting evidence in the original guideline, where the Search Plan and
Results can be found. Here the reader can view when the search plan was performed, specific inclusion and exclusion
criteria, search terms, data bases that were searched, and the excluded articles.
Number of Source Documents
The number of supporting documents for the recommendations is 24.
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Conclusion Grading Table
Strength of
Evidence Elements

Grade I

Grade II

Grade III

Grade IV

Good/Strong

Fair

Limited/Weak

Expert Opinion Only

Grade V
Grade Not
Assignable

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Conclusion Grading Table
Strength of
Evidence Elements

Grade I

Grade II

Grade III

Grade IV

Grade V

Good/Strong

Fair

Limited/Weak

Expert Opinion Only

Grade Not
Assignable

Quality
Scientific
rigor/validity
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Considers
design and
execution
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Studies of strong design for

question
Free from design flaws, bias
and execution problems

Studies of strong
design for question
with minor
methodological
concerns
OR

Studies of weak design for No studies available

answering the question
Conclusion based on usual
OR
practice, expert consensus,
clinical experience, opinion,
Inconclusive findings due
or extrapolation from basic
to design flaws, bias or
research
execution problems

No evidence
that pertains to
question being
addressed

Only studies of
weaker study design
for question
Consistency
Of findings across
studies

Quantity
Numberof
studies
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Numberof
subjects in
studies
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Findings generally consistent in

direction and size of effect or
degree of association, and
statistical significance with
minor exceptions at most

One to several good quality

studies
Large number of subjects
studied

Studied outcome relates

Importanceof directly to the question
studies outcomes Size of effect is clinically
meaningful
l Magnitudeof
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Generalizability
To population of
interest

OR

OR

Consistency with
minor exceptions
across studies of
weaker designs

Single study unconfirmed

by other studies

Several studies by
independent
investigators

Limited number of studies

Doubts about
adequacy of sample
Studies with negative results
size to avoid Type I
having sufficiently large sample
and Type II error
size for adequate statistical
power

Clinical Impact

effect

Inconsistency among Unexplained inconsistency

results of studies with among results from
strong design
different studies

Low number of subjects

studied and/or inadequate
sample size within studies

Some doubt about

Studied outcome is an
the statistical or
intermediate outcome or
clinical significance of surrogate for the true
effect
outcome of interest

Significant (statistical)
difference is large

Studied population,
Minor doubts about
intervention and outcomes are generalizability
free from serious doubts about
generalizability

Conclusion supported solely

by statements of informed
nutrition or medical
commentators

NA

Unsubstantiated by published Relevant studies

studies
have not been
done

Objective data unavailable

Indicates area
for future
research

Generalizability limited to
scope of experience

NA

OR
Size of effect is small or
lacks statistical and/or
clinical significance
Serious doubts about
generalizability due to
narrow or different study
population, intervention or
outcomes studied

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to
evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading
system to this current version.

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
Step 1: Formulate Evidence Analysis Question
Specify a question in a defined area of practice; or state a tentative conclusion or recommendation that is being
considered. Include the patient type and special needs of the target population involved, the alternatives under
consideration, and the outcomes of interest (PICO format).
Step 2: Gather and Classify Evidence
Conduct a systematic search of the literature to find evidence related to the question, gather studies and reports, and
classify them by type of evidence. Classes differentiate primary reports of new data according to study design, and
distinguish them from secondary reports that include systematic and/or narrative review.
Step 3: Critically Appraise Each Article
Review each article for relevance to the question and use the checklist of questions to evaluate the research design and
implementation. Abstract key information from the report.
Step 4: Summarize Evidence
Synthesize the reports into an overview table and summarize the research relevant to the question.
Step 5: Write and Grade the Conclusion Statement
Develop a concise conclusion statement (the answer to the question). Assign a grade to indicate the overall strength or
weakness of evidence informing the conclusion statement (see "Rating Scheme for the Strength of the Evidence").
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Synthesize the reports into an overview table and summarize the research relevant to the question.
Step 5: Write and Grade the Conclusion Statement
Develop a concise conclusion statement (the answer to the question). Assign a grade to indicate the overall strength or
weakness of evidence informing the conclusion statement (see "Rating Scheme for the Strength of the Evidence").
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Moving From Analysis to the Evidence-Based Nutrition Practice Guideline
The expert workgroup, which includes practitioners and researchers with a depth of experience in the specific field of
interest, develops the disease-specific guideline. The guideline development involves the following steps.
Review the Conclusion Statements
The workgroup meets to review the materials resulting from the evidence analysis, which may include review of the
conclusion statements, evidence summaries and evidence worksheets.
Formulate Recommendations for the Guideline Integrating Conclusions from Evidence Analysis
The workgroup uses an expert consensus method to formulate the guideline recommendations and complete the various
sections on the recommendation page. These include:
Recommendation(s): This is a course of action for the practitioner. The recommendation is written using two brief
and separate statements. The first statement is "what" the dietitian should do or not do? The second statement
describes the "why" of the recommendation. More than one recommendation may be formulated depending on a
particular topic and the supporting conclusion statements.
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Rating: The rating for the recommendation is based on the strength of the supporting evidence. The grade of the
supporting conclusion statement(s) will be help determining this rating (see "Rating Scheme for the Strength of the
Recommendation").
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Label of Conditional or Imperative: Each recommendation will have a label of "conditional" or "imperative".
Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the
target population without restraints on their pertinence.
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Risks and Harms of Implementing the Recommendation: Includes any potential risks, anticipated harms or
adverse consequences associated with applying the recommendation(s) to the target population.
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Conditions of Application: Includes any organizational barriers or changes that would need to be made within an
organization to apply the recommendation in daily practice. Also includes any conditions which may limit the application
of the recommendation(s). For instance, application may be limited to only people in an inpatient setting, or not
applicable for pregnant women. Conditional recommendations will always have conditions specified. Imperative
recommendations may have some general conditions for application.
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Potential Costs Associated with Application: Includes any costs that may be associated with the application of this
recommendation such as specialized staff, new equipment or treatments.
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Recommendation Narrative: Provides a brief description of the evidence that supports this recommendation.

Recommendation Strength Rationale: Provides a brief list of the evidence strength and methodological issues that
determined the recommendation strength.
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Minority Opinions: If the expert workgroup cannot reach consensus on the recommendation, the minority opinions
may be listed here.
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Supporting Evidence: Provides links to the conclusions statements, evidence summaries and worksheets related to
the formulation of this recommendation(s).
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References Not Graded in the American Dietetic Association's (ADA) Evidence Analysis Process:
Recommendations will be based on the summarized evidence from the analysis. Sources that were not analyzed during
the evidence analysis process may be used to support and formulate the recommendation or to support information
under other categories on the recommendation page, if the workgroup deems necessary. References must be credible
resources (e.g., consensus reports, other guidelines, position papers, standards of practice, articles from peer -reviewed
journals, nationally recognized documents or websites). If recommendations are based solely on these types of
references, they will be rated as "consensus."
Occasionally recommendations will include references that were not reviewed during the evidence analysis process but
are relevant to the recommendation, risks and harms of implementing the recommendation, conditions of application, or
potential costs associated with application. These references will be listed on the recommendation page under
"References Not Graded in ADA's Evidence Analysis Process."
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Develop a Clinical Algorithm for the Guideline

The workgroup develops a clinical algorithm based on ADA's Nutrition Care Process, to display how each recommendation
can be used within the treatment process and how they relate to the Nutrition Assessment, Diagnosis, Intervention, and
Monitoring and Evaluation.
Complete the Writing of the Guideline
Each disease-specific guideline has a similar format which incorporates the Introduction (includes: Scope of the Guideline,
Statement of Intent, Guideline Methods, Implementation, Benefits and Risks/Harms of Implementation), Background
Information, and any necessary Appendices. The workgroup develops these features.
Criteria Used in Guideline Development
The criteria used in determining the format and process for development of ADA's guidelines is based on the following
tools and criteria for evidence-based guidelines:
GuidelineElementsModel(GEM),whichhasbeenincorporatedbytheAmericanSocietyforTestingandMaterials
(ASTM) as a Standard Specification for clinical practice guidelines.
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AGREE(AppraisalforGuidelinesResearchandEvaluation)Instrument

NationalGuidelineClearinghouse(www.guideline.gov )

Rating Scheme for the Strength of the Recommendations

Criteria for Recommendation Rating

GuidelineElementsModel(GEM),whichhasbeenincorporatedbytheAmericanSocietyforTestingandMaterials
(ASTM) as a Standard Specification for clinical practice guidelines.
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AGREE(AppraisalforGuidelinesResearchandEvaluation)Instrument

NationalGuidelineClearinghouse(www.guideline.gov )

Rating Scheme for the Strength of the Recommendations

Criteria for Recommendation Rating
Statement

Definition

Implication for Practice

Rating

Strong

A Strong recommendation means that the workgroup believes that the benefits
of the recommended approach clearly exceed the harms (or that the harms
clearly exceed the benefits in the case of a strong negative recommendation),
and that the quality of the supporting evidence is excellent/good (grade I or
II).* In some clearly identified circumstances, strong recommendations may be
made based on lesser evidence when high-quality evidence is impossible to
obtain and the anticipated benefits strongly outweigh the harms.

Practitioners should follow a Strong recommendation

unless a clear and compelling rationale for an
alternative approach is present.

Fair

A Fair recommendation means that the workgroup believes that the benefits
Practitioners should generally follow a Fair
exceed the harms (or that the harms clearly exceed the benefits in the case of a recommendation but remain alert to new information
negative recommendation), but the quality of evidence is not as strong (grade II and be sensitive to patient preferences.
or III).* In some clearly identified circumstances, recommendations may be made
based on lesser evidence when high-quality evidence is impossible to obtain and
the anticipated benefits outweigh the harms.

Weak

A Weak recommendation means that the quality of evidence that exists is

suspect or that well-done studies (grade I, II, or III)* show little clear
advantage to one approach versus another.

Practitioners should be cautious in deciding whether

to follow a recommendation classified as Weak, and
should exercise judgment and be alert to emerging
publications that report evidence. Patient preference
should have a substantial influencing role.

Consensus

A Consensus recommendation means that Expert opinion (grade IV)* supports

the guideline recommendation even though the available scientific evidence did
not present consistent results, or controlled trials were lacking.

Practitioners should be flexible in deciding whether to

follow a recommendation classified as Consensus,
although they may set boundaries on alternatives.
Patient preference should have a substantial
influencing role.

Insufficient
Evidence

An Insufficient Evidence recommendation means that there is both a lack of

pertinent evidence (grade V)* and/or an unclear balance between benefits and
harms.

Practitioners should feel little constraint in deciding

whether to follow a recommendation labeled as
Insufficient Evidence and should exercise judgment
and be alert to emerging publications that report
evidence that clarifies the balance of benefit versus
harm. Patient preference should have a substantial
influencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV
signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the
conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see
chart above) to a recommendation.
Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice
Guideline, Pediatrics. 2004;114;874-877.

Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
Each guideline is reviewed internally and externally using the AGREE (Appraisal of Guidelines for Research and Evaluation)
instrument as the evaluation tool. The external reviewers consist of a multidisciplinary group of individuals (may include
dietitians, doctors, psychologists, nurses, etc.). The guideline is adjusted by consensus of the expert panel and approved
by American Dietetic Association's Evidence-Based Practice Committee prior to publication on the Evidence Analysis
Library (EAL).

Recommendations
Major Recommendations
Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion
grades (I-V), and statement labels (Conditional versus Imperative) are defined at the end of the "Major
Recommendations" field.
Chronic Kidney Disease (CKD) Medical Nutrition Therapy (Non-Dialysis)
CKD: Medical Nutrition Therapy
Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals with chronic kidney
disease (CKD, Stages One to Five including post-kidney transplant). MNT prevents and treats protein-energy malnutrition
and mineral and electrolyte disorders and minimizes the impact of other comorbidities on the progression of kidney
disease (e.g., diabetes, obesity, hypertension and disorders of lipid metabolism). Studies regarding effectiveness of MNT
report significant improvements in anthropometric and biochemical measurements sustained for at least one year.
Strong, Imperative
CKD: Initiation of Medical Nutrition Therapy

Chronic Kidney Disease (CKD) Medical Nutrition Therapy (Non-Dialysis)

CKD: Medical Nutrition Therapy
Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals with chronic kidney
disease (CKD, Stages One to Five including post-kidney transplant). MNT prevents and treats protein-energy malnutrition
and mineral and electrolyte disorders and minimizes the impact of other comorbidities on the progression of kidney
disease (e.g., diabetes, obesity, hypertension and disorders of lipid metabolism). Studies regarding effectiveness of MNT
report significant improvements in anthropometric and biochemical measurements sustained for at least one year.
Strong, Imperative
CKD: Initiation of Medical Nutrition Therapy
Referral for MNT per federal or state guidelines should be initiated at diagnosis of CKD, in order to maintain adequate
nutritional status, prevent disease progression and delay renal replacement therapy (RRT). MNT should be initiated at
least 12 months prior to the anticipation of RRT (dialysis or transplant).
Strong, Imperative
CKD: Frequency of Medical Nutrition Therapy
Depending on the care setting and the initiation of MNT, the RD should monitor the nutritional status of individuals with
CKD every one to three months and more frequently if there is inadequate nutrient intake, protein-energy malnutrition,
mineral and electrolyte disorders or the presence of an illness that may worsen nutritional status, as these are predictive
of increased mortality risk. Research related to the time requirements for MNT provided by an RD indicate that
approximately two hours per month for up to one year may be required to provide an effective intervention for adults with
CKD.
Strong, Conditional
Recommendation Strength Rationale
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ConclusionstatementswereGradeI.

TheAmericanDieteticAssociation(ADA)CKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKidney
Disease Outcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.
KDOQI group members accepted the guideline statements as valid if the median panel rating was seven or greater on a
scale of one to nine.
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CKD Assessment of Food/Nutrition-Related History

CKD: Initial Assessment of Food/Nutrition-Related History
The registered dietitian should assess the food- and nutrition-related history of adults with chronic kidney disease
(including post kidney transplant), including but not limited to the following:
Foodandnutrientintake(e.g.,diethistory,dietexperienceandintakeofmacronutrients[andmicronutrients,such
as energy, protein, sodium, potassium, calcium, phosphorus, and others], as appropriate)
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Medication(prescriptionandover-the-counter), dietary supplements (vitamin, minerals, protein, etc.), herbal or

botanical supplement use
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Knowledge,beliefsorattitudes(e.g.,readinesstochangenutritionandlifestylebehaviors)

Behavior

Factorsaffectingaccesstofoodandfoodandnutrition-related supplies (e.g., safe food and meal availability)

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition
interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
Consensus, Imperative
CKD: Reassessment of Food/Nutrition-Related History
On subsequent visits, the RD should reassess the food- or nutrition-related history of adults with CKD (including post
kidney transplant), related to changes in other assessment parameters (laboratory and anthropometric changes),
including but not limited to the following:
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Foodandnutrientintake,targetedtochangesinbiochemicalparameters

Medication,dietarysupplements,herbalorbotanicalsupplementuse

Knowledge,beliefsorattitudes

Behavior

Factorsaffectingaccesstofoodandfoodandnutrition-related supplies

Assessment of the above factors is needed to explain changes in the other assessment parameters and plan additional
nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
Consensus, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for
Nutrition in Chronic Renal Failure.
CKD Anthropometric Assessment Options
CKD: Use Clinical Judgment in Assessing Body Weight
Due to the absence of standard reference norms in the chronic kidney disease population (CKD, including post kidney
transplant), the registered dietitian should use clinical judgment to determine which data to include in estimations of
body weight:
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Actualmeasuredweight

Historyofweightchanges(bothlong-term and recent)

Serialweightmeasurements,monitoredlongitudinally

Adjustmentsforsuspectedimpactofedema,ascitesandpolycysticorgans

Body weight estimates are used for calculation of nutritional needs, such as protein and energy requirements. Body
weight can be difficult to determine because as kidney function declines, the ability to regulate fluid balance may be
compromised and multiple factors must be considered.
Consensus, Imperative

Actualmeasuredweight

Historyofweightchanges(bothlong-term and recent)

Serialweightmeasurements,monitoredlongitudinally

Adjustmentsforsuspectedimpactofedema,ascitesandpolycysticorgans

Body weight estimates are used for calculation of nutritional needs, such as protein and energy requirements. Body
weight can be difficult to determine because as kidney function declines, the ability to regulate fluid balance may be
compromised and multiple factors must be considered.
Consensus, Imperative
CKD: Use Published Weight Norms with Caution
The RD may use other published weight norms in the anthropometric assessment of individuals with CKD (including post
kidney transplant), but each norm has significant drawbacks and must be used with caution:
Idealbodyweight(IBW)isthebodyweightassociatedwiththelowestmortalityforagivenheight,age,sexand
frame size and is based on the Metropolitan Life Insurance Height and Weight Tables. (Caution: Not generalizable to
the CKD population and data-gathering methods were not standardized.)
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HamwiMethoddeterminestheoptimalbodyweight.(Caution:Aquickandeasymethodfordeterminingoptimal
body weight, but has no scientific data to support its use.)
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StandardBodyWeight,NationalHealthandNutritionExaminationSurvey(NHANESII)(SBWasperKDOQINutrition
Practice Guidelines) describes the median body weight of average Americans from 1976 to 1980 for height, age, sex and
frame size. (Caution: Although data is validated and standardized and uses a large database of ethnically-diverse
groups, data is provided only on what individuals weigh, not what they should weigh in order to reduce morbidity and
mortality.)
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BodyMassIndex(BMI)oftendefinesgeneralizedobesityandCKDresearch,specifictodialysispatients,has
identified that patients at higher BMIs have a lower mortality risk. (Caution: The researchers may not have statistically
adjusted for all confounders related to comorbid conditions occurring in CKD on dialysis [diabetes, malignancy, etc.] and
it is unclear how it may relate to CKD patients not on dialysis.)
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AdjustedBodyWeight(ABW)isbasedonthetheorythat25%oftheexcessbodyweight(adiposetissue)inobese
patients is metabolically active tissue. KDOQI supports the concept of subtracting 25% for obese patients and adding
25% for underweight patients. (Caution: This has not been validated for use in CKD and may either overestimate or
underestimate energy and protein requirements.)
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Body weight estimates are used for calculation of nutritional needs, such as protein and energy requirements. Body
weight can be difficult to determine because as kidney function declines, the ability to regulate fluid balance may be
compromised and multiple factors must be considered.
Consensus, Conditional
CKD: Assessment of Body Composition
The RD should assess the body composition of individuals with CKD (including post kidney transplant). Studies suggest
that CKD patients exhibit altered body composition, as compared to healthy individuals.
Fair, Imperative
CKD: Methodologies for Body Composition Assessment
When assessing the body composition of individuals with CKD (including post kidney transplant), the RD may use any
valid measurement methodology, such as anthropometrics (including waist circumference and body mass index) and body
compartment estimates. Currently, there is no reference standard for assessing body composition in CKD patients and
studies do not show that any one test is superior to another in assessing body composition among CKD patients.
Fair, Imperative
Recommendation Strength Rationale
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ConclusionstatementwasGradeII.

TheADACKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKDOQIClinicalPracticeGuidelinesfor
Nutrition in Chronic Renal Failure.
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CKD Assessment of Biochemical Parameters

CKD: Assess Biochemical Parameters
The RD should assess various biochemical parameters in adults with chronic kidney disease (including post-kidney
transplant), related to:
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Glycemiccontrol

Protein-energy malnutrition

Inflammation

Kidneyfunction

Mineralandbonedisorders

Anemia

Dyslipidemia

Electrolytedisorders

Othersasappropriate

Assessment of the above factors is needed to effectively determine the nutrition diagnoses and nutrition prescription in
adults with CKD and post-kidney transplant.
Consensus, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:
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NutritioninChronicRenalFailure

BoneMetabolismandDiseaseinChronicKidneyDisease

AnemiainChronicKidneyDisease

CKD Assess CKD-Mineral and Bone Disorders

adults with CKD and post-kidney transplant.

Consensus, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:
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NutritioninChronicRenalFailure

BoneMetabolismandDiseaseinChronicKidneyDisease

AnemiainChronicKidneyDisease

CKD Assess CKD-Mineral and Bone Disorders

CKD: Assess CKD-Mineral and Bone Disorders
The RD should assess measurements of mineral and bone disorders (MBD) in adults with chronic kidney disease (including
post kidney transplant) for prevention and treatment. Adults with CKD have altered mineral-bone metabolism and
increased risk of vascular disease.
Consensus, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone
Metabolism and Disease in Chronic Kidney Disease.
CKD Assessment of Medical/Health History
CKD: Assessment of Medical/Health History
When implementing MNT, the RD should assess the medical and health history of individuals with CKD (including post
kidney transplant) for the presence of other disease states and conditions, such as diabetes, hypertension, obesity and
disorders of lipid metabolism. Adults with CKD, including post kidney transplant, have a higher prevalence of
comorbidities, which are risk factors for the progression of kidney disease.
Strong, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:
l

HypertensionandAntihypertensiveAgentsinChronicKidneyDisease

ManagingDyslipidemiasinChronicKidneyDisease

DiabetesandChronicKidneyDisease

CKD Protein Intake

CKD: Protein Intake for Estimated Glomerular Filtration Rate (eGFR) <50 ml per minute per 1.73m 2
For adults with CKD without diabetes, not on dialysis, with eGFR below 50ml per minute per 1.73m 2, the RD should
recommend or prescribe a protein-controlled diet providing 0.6 g to 0.8 g dietary protein per kg of body weight per day.
Clinical judgment should be used when recommending lower protein intakes, considering the client's level of motivation,
willingness to participate in frequent follow-up and risk for protein-energy malnutrition. Research reports that proteinrestricted diets (0.7 g dietary protein per kg of body weight per day, ensuring adequate caloric intake) can slow GFR
decline and maintain stable nutrition status in adult non-diabetic patients with CKD.
Strong, Conditional
CKD: Very-Low-Protein Intake for eGFR <20 ml per minute per 1.73m 2
In international settings where keto acid analogs are available, a very-low protein-controlled diet may be considered. For
adults with CKD without diabetes, not on dialysis, with an eGFR below 20 ml per minute per 1.73m 2, a very-low proteincontrolled diet providing 0.3 g to 0.5 g dietary protein per kg of body weight per day with addition of keto acid analogs to
meet protein requirements may be recommended. International studies report that additional keto acid analogs and
vitamin or mineral supplementation are needed to maintain adequate nutrition status for patients with CKD who consume
a very-low-protein controlled diet (0.3 g to 0.5 g per kg per day).
Strong, Conditional
CKD: Protein Intake for Diabetic Nephropathy
For adults with diabetic nephropathy, the RD should recommend or prescribe a protein-controlled diet providing 0.8 g to
0.9 g of protein per kg of body weight per day. Providing dietary protein at a level of 0.7 g per kg of body weight per day
may result in hypoalbuminemia. Research reports that protein-restricted diets improved microalbuminuria.
Fair, Conditional
CKD: Protein Intake for Kidney Transplant
For adult kidney transplant recipients (after surgical recovery, with an adequately functioning allograft), the RD should
recommend 0.8 g to 1.0 g per kg of body weight per day for protein intake, addressing specific issues as needed.
Adequate, but not excessive, protein intake supports allograft survival and minimizes impact on comorbid conditions.
Consensus, Conditional
Recommendation Strength Rationale
FortheCKD:ProteinIntake(Non-dialysis) for eGFR <50 ml per minute per 1.73m 2 recommendation, the conclusion
statement was Grade I.
l

FortheCKD:Very-Low-Protein Intake (Non-dialysis) for eGFR <20 ml per minute per 1.73m 2 recommendation, the
conclusion statement was Grade I.
l

FortheCKD:ProteinIntakeforDiabeticNephropathyrecommendation,theconclusionstatementwasGradeII.

FortheCKD:ProteinIntakeforKidneyTransplantrecommendation,theconclusionstatementwasGradeIII.

CKD Energy Intake

CKD: Energy Intake
For adults with CKD (including post kidney transplant after surgical recovery), the RD should recommend or prescribe an
energy intake between 23 kcal to 35 kcal per kg of body weight per day, based on the following factors:
l

Weightstatusandgoals

Ageandgender

FortheCKD:ProteinIntakeforDiabeticNephropathyrecommendation,theconclusionstatementwasGradeII.

FortheCKD:ProteinIntakeforKidneyTransplantrecommendation,theconclusionstatementwasGradeIII.

CKD Energy Intake

CKD: Energy Intake
For adults with CKD (including post kidney transplant after surgical recovery), the RD should recommend or prescribe an
energy intake between 23 kcal to 35 kcal per kg of body weight per day, based on the following factors:
l

Weightstatusandgoals

Ageandgender

Levelofphysicalactivity

Metabolicstressors

Research reports that energy intakes between 23 kcal to 35 kcal per kg body weight per day are adequate to prevent
signs of malnutrition.
Fair, Imperative
Recommendation Strength Rationale
l

ConclusionstatementinsupportofthisrecommendationwasGradeII.

TheADACKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKDOQIClinicalPracticeGuidelinesfor
Nutrition in Chronic Renal Failure.
l

CKD Phosphorus
CKD: Phosphorus
For adults with CKD (Stages Three to Five), the RD should recommend or prescribe a low-phosphorus diet providing 800
mg to 1,000 mg per day or 10 mg to 12 mg phosphorus per gram of protein. CKD patients have a predisposition for
mineral and bone disorders. Phosphorus control is the cornerstone for the treatment and prevention of secondary
hyperparathyroidism, renal bone disease and soft tissue calcification.
Strong, Conditional
CKD: Adjust Phosphate Binders
For adults with CKD (Stages Three to Five), the dose and timing of phosphate binders should be individually adjusted to
the phosphate content of meals and snacks to achieve desired serum phosphorus levels. Serum phosphorus levels are
difficult to control with dietary restrictions alone.
Strong, Conditional
CKD: Phosphorus Management for Kidney Transplant
For adult kidney transplant recipients exhibiting hypophosphatemia, the RD should recommend or prescribe a highphosphorus intake (diet or supplements) to replete serum phosphorus as needed. Hypophosphatemia is common post
kidney transplant.
Consensus, Conditional
Recommendation Strength Rationale
l

ConclusionstatementwasGradeII.

TheADACKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKDOQIClinicalPracticeGuidelinesfor
Bone Metabolism and Disease in Chronic Kidney Disease.
l

CKD Calcium
CKD: Calcium
For adults with CKD (Stages Three to Five, including post kidney transplant), the RD should recommend a total elemental
calcium intake (including dietary calcium, calcium supplementation and calcium-based phosphate binders) not exceeding
2, 000 mg per day. CKD patients have a predisposition for mineral and bone disorders. Serum calcium concentration is the
most important factor regulating parathyroid hormone (PTH) secretion affecting bone integrity and soft tissue
calcification.
Consensus, Conditional
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone
Metabolism and Disease in Chronic Kidney Disease.
CKD Vitamin D Therapy
CKD: Vitamin D Supplementation
In adults with CKD (including post kidney transplant), the RD should recommend vitamin D supplementation to maintain
adequate levels of vitamin D if the serum level of 25-hydroxyvitamin D is less than 30 ng per ml (75 nmol per L). CKD
patients have a predisposition for mineral and bone disorders, as well as other conditions that may be affected by
insufficient vitamin D. Sufficient vitamin D should be recommended to maintain adequate levels of serum vitamin D.
Consensus, Conditional
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for Bone
Metabolism and Disease in Chronic Kidney Disease.
CKD Anemia
CKD: Iron Supplementation
In adults with CKD (including post kidney transplant), the RD should recommend oral or intravenous (IV) iron
administration if serum ferritin is below 100 ng per ml and transferrin saturation (TSAT) is below 20%. CKD patients have
a predisposition for anemia. Sufficient iron should be recommended to maintain adequate levels of serum iron to support
erythropoiesis.
Consensus, Conditional
CKD: Vitamin B12 and Folic Acid for Anemia
In adults with CKD (including post kidney transplant), the RD should recommend vitamin B12 and folic acid
supplementation if the mean corpuscular volume (MCV) is over 100 ng per ml and serum levels of these nutrients are

CKD: Iron Supplementation

In adults with CKD (including post kidney transplant), the RD should recommend oral or intravenous (IV) iron
administration if serum ferritin is below 100 ng per ml and transferrin saturation (TSAT) is below 20%. CKD patients have
a predisposition for anemia. Sufficient iron should be recommended to maintain adequate levels of serum iron to support
erythropoiesis.
Consensus, Conditional
CKD: Vitamin B12 and Folic Acid for Anemia
In adults with CKD (including post kidney transplant), the RD should recommend vitamin B12 and folic acid
supplementation if the mean corpuscular volume (MCV) is over 100 ng per ml and serum levels of these nutrients are
below normal values. CKD patients have a predisposition for anemia and all potential causes should be investigated.
Consensus, Conditional
CKD: Vitamin C for Treatment of Anemia
If the use of vitamin C supplementation is proposed as a method to improve iron absorption for adults with CKD
(including post kidney transplant) who are anemic, the RD should recommend the dietary reference intakes (DRI) for
vitamin C. There is insufficient evidence to recommend the use of vitamin C supplementation above the DRI in the
management of anemia in patients with CKD, due to risk of hyperoxalosis.
Consensus, Conditional
CKD: L-Carnitine for Treatment of Anemia
For adults with CKD (including post kidney transplant) who are anemic, the RD should not recommend L-carnitine
supplementation. There is insufficient evidence to recommend the use of L-carnitine in the management of anemia in
adults with CKD including post kidney transplant.
Consensus, Conditional
Recommendation Strength Rationale
l

ConclusionstatementwasGradeII.

TheADACKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKDOQIClinicalPracticeGuidelinesfor
Anemia in Chronic Kidney Disease.
l

CKD Management of Hyperglycemia in Diabetes and CKD

CKD: Management of Hyperglycemia in Diabetes and CKD
For adults with diabetes and CKD (including post kidney transplant), the RD should implement MNT for diabetes care to
manage hyperglycemia to achieve a target A1C of approximately 7%. Intensive treatment of hyperglycemia, while
avoiding hypoglycemia, prevents diabetic kidney disease (DKD) and may slow progression of established kidney disease.
Strong, Conditional
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines and
Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease.
CKD Multi-Faceted Approach to Intervention in Diabetes and CKD
CKD: Multi-Faceted Approach to Intervention in Diabetes and CKD
For adults with diabetes and CKD (including post kidney transplant), the RD should implement MNT using a multi-faceted
approach, including education and counseling in healthy behaviors, treatment to reduce risk factors and self-management
strategies. Multiple risk factors are managed concurrently in adults with diabetes and CKD and the incremental effects of
treating each of these risk factors results in substantial clinical benefits.
Consensus, Conditional
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines and
Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease.
CKD Multi-Faceted Approach to Intervention in Dyslipidemias and CKD
CKD: Multi-Faceted Approach to Intervention in Dyslipidemias and CKD
For adults with dyslipidemia and CKD (including post kidney transplant), the RD should implement MNT, using a multifaceted approach, including education and counseling in therapeutic lifestyle changes (TLC), treatment to reduce risk
factors and self-management strategies. Multiple risk factors are managed concurrently in adults with dyslipidemia and
CKD and the incremental effects of treating each of these risk factors results in substantial clinical benefits.
Fair, Conditional
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:
l

ManagingDyslipidemiasinChronicKidneyDisease

DiabetesandChronicKidneyDisease

CKD Education on Self-Management Behaviors

CKD: Education on Self-Management Behaviors
For individuals with CKD (including post kidney transplant), the RD should provide education and counseling regarding
self-management behaviors. Therapy must take into consideration the patient's perception of the health-care provider's
advice and prescriptions, factors that may influence self-management behaviors and the likelihood that the patient will
adhere to recommendations.
Fair, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on
Hypertension and Antihypertensive Agents in Chronic Kidney Disease.
CKD Sodium
CKD: Control Sodium Intake in CKD
For adults with CKD (including post-kidney transplant) the RD should recommend/prescribe a sodium intake of less than

self-management behaviors. Therapy must take into consideration the patient's perception of the health-care provider's
advice and prescriptions, factors that may influence self-management behaviors and the likelihood that the patient will
adhere to recommendations.
Fair, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines on
Hypertension and Antihypertensive Agents in Chronic Kidney Disease.
CKD Sodium
CKD: Control Sodium Intake in CKD
For adults with CKD (including post-kidney transplant) the RD should recommend/prescribe a sodium intake of less than
2.4 g (Stages One to Five), with adjustments based on the following:
l

Bloodpressure

Medications

Kidneyfunction

Hydrationstatus

Acidosis

Glycemiccontrol

Catabolism

Gastrointestinalissues,includingvomiting,diarrheaandconstipation

Dietary and other therapeutic lifestyle modifications are recommended as part of a comprehensive strategy to reduce
cardiovascular disease risk in adults with CKD.
Fair, Imperative
Recommendation Strength Rationale
l

ConclusionstatementreceivedGradeII.

TheADACKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKDOQIClinicalPracticeGuidelineson
Hypertension and Antihypertensive Agents in Chronic Kidney Disease and the Clinical Practice Recommendations for
Diabetes and Chronic Kidney Disease.
l

CKD Fish Oil/Omega-3 Fatty Acids

CKD: Fish Oil/Omega-3 Fatty Acids
If the use of fish oil or omega-3 fatty acid supplementation is proposed as a method to improve renal function, the RD
should advise on the conflicting evidence regarding effectiveness of this strategy. Research reports that renal outcomes
were inconsistent among patients with immunoglobulin A (IgA) nephropathy who received fish oil supplementation. There
is insufficient evidence to support fish oil therapy to improve renal function and patient or graft survival for kidney
transplant patients. However, evidence does support a benefit of fish oil supplementation in reducing oxidative stress
and improving lipid profile in adults with CKD (including post kidney transplant).
Fair, Conditional
Recommendation Strength Rationale
Conclusion statements were Grades II and III.
CKD Physical Activity
CKD: Physical Activity
If not contraindicated, the RD should encourage adults with CKD (including post kidney transplant), to increase frequency
or duration of physical activity as tolerated. Studies report that physical activity may minimize the catabolic effects of
protein restriction and improve quality of life.
Fair, Conditional
Recommendation Strength Rationale
Conclusion statements were Grade III.
CKD Coordination of Care
CKD: Coordination of Care
For adults with CKD (including post kidney transplant), the RD should implement MNT and coordinate care with an
interdisciplinary team, through:
l

Requestingappropriatedata(biochemicalandother)

Communicatingwithreferringprovider

Indicatingspecificareasofconcernorneededreinforcement.

This approach is necessary to effectively integrate MNT into overall management for patients with CKD.
Consensus, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for
Nutrition in Chronic Renal Failure.
CKD Multivitamin Supplementation
CKD: Multivitamin Supplementation
In adults with CKD (including post kidney transplant), with no known nutrient deficiency (biochemical or physical) and who
may be at higher nutritional risk due to poor dietary intake and decreasing GFR, the RD should recommend or prescribe a
multivitamin preparation. Sufficient vitamin supplementation should be recommended to maintain indices of adequate
nutritional status.
Consensus, Conditional
Recommendation Strength Rationale
l

ConclusionstatementwasGradeIII.

CKD Multivitamin Supplementation

CKD: Multivitamin Supplementation
In adults with CKD (including post kidney transplant), with no known nutrient deficiency (biochemical or physical) and who
may be at higher nutritional risk due to poor dietary intake and decreasing GFR, the RD should recommend or prescribe a
multivitamin preparation. Sufficient vitamin supplementation should be recommended to maintain indices of adequate
nutritional status.
Consensus, Conditional
Recommendation Strength Rationale
l

ConclusionstatementwasGradeIII.

TheADACKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKDOQIClinicalPracticeGuidelinesfor
Bone Metabolism and Disease in Chronic Kidney Disease.
l

CKD Potassium
CKD: Control Potassium Intake in CKD
For adults with CKD (including post kidney transplant) who exhibit hyperkalemia, the RD should recommend or prescribe a
potassium intake of less than 2.4 g (Stages Three to Five), with adjustments based on the following:
l

Serumpotassiumlevel

Bloodpressure

Medications

Kidneyfunction

Hydrationstatus

Acidosis

Glycemiccontrol

Catabolism

Gastrointestinal(GI)issues,includingvomiting,diarrhea,constipationandGIbleed

Dietary and other therapeutic lifestyle modifications are recommended as part of a comprehensive strategy to reduce
cardiovascular disease risk in adults with CKD. The degree of hypokalemia or hyperkalemia can have a direct effect on
cardiac function, with potential for cardiac arrhythmia and sudden death.
Fair, Conditional
Recommendation Strength Rationale
l

ConclusionstatementwasGradeII.

TheADACKDExpertWorkGroupconcurswiththeNationalKidneyFoundationKDOQIClinicalPracticeGuidelineson
Hypertension and Antihypertensive Agents in Chronic Kidney Disease and the Clinical Practice Recommendations for
Diabetes and Chronic Kidney Disease.
l

CKD Monitor and Evaluate Biochemical Parameters

CKD: Monitor and Evaluate Biochemical Parameters
The RD should monitor and evaluate various biochemical parameters in adults with CKD (including post kidney
transplant), related to:
l

Glycemiccontrol

Protein-energy malnutrition

Inflammation

Kidneyfunction

Mineralandbonedisorders

Anemia

Dyslipidemia

Electrolytedisorders

Othersasappropriate

Monitoring and evaluation of the above factors is needed to determine the effectiveness of MNT in adults with CKD and
post kidney transplant.
Consensus, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for:
l

NutritioninChronicRenalFailure

BoneMetabolismandDiseaseinChronicKidneyDisease

AnemiainChronicKidneyDisease

CKD Monitor and Evaluate Adherence to Nutrition and Lifestyle Recommendations

CKD: Monitor and Evaluate Adherence to Nutrition and Lifestyle Recommendations
The RD should monitor the following in adults with CKD (including post kidney transplant):
Foodandnutrientintake(e.g.,diethistory,dietexperienceandintakeofmacronutrientsandmicronutrients,suchas
energy, protein, sodium, potassium, calcium, phosphorus and others, as appropriate)
l

Medication(prescriptionandover-the-counter), dietary supplements (vitamin, minerals, protein, etc.), herbal or

botanical supplement use
l

Knowledge,beliefsorattitudes(e.g.,readinesstochangenutritionandlifestylebehaviors)

Behavior

Factorsaffectingaccesstofoodandfood- and nutrition-related supplies (e.g., safe food and meal availability)

Monitoring and evaluation of the above factors is needed to determine the effectiveness of MNT in adults with CKD and

The RD should monitor the following in adults with CKD (including post kidney transplant):
Foodandnutrientintake(e.g.,diethistory,dietexperienceandintakeofmacronutrientsandmicronutrients,suchas
energy, protein, sodium, potassium, calcium, phosphorus and others, as appropriate)
l

Medication(prescriptionandover-the-counter), dietary supplements (vitamin, minerals, protein, etc.), herbal or

botanical supplement use
l

Knowledge,beliefsorattitudes(e.g.,readinesstochangenutritionandlifestylebehaviors)

Behavior

Factorsaffectingaccesstofoodandfood- and nutrition-related supplies (e.g., safe food and meal availability)

Monitoring and evaluation of the above factors is needed to determine the effectiveness of MNT in adults with CKD and
post kidney transplant.
Consensus, Imperative
Recommendation Strength Rationale
The ADA CKD Expert Work Group concurs with the National Kidney Foundation KDOQI Clinical Practice Guidelines for
Nutrition in Chronic Renal Failure.
Definitions:
Conditional versus Imperative Recommendations
Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a
specific situation, while imperative statements are broadly applicable to the target population without restraints on their
pertinence. More specifically, a conditional recommendation can be stated in if/then terminology (e.g., If an individual
does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be
recommended for secondary prevention).
In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain
conditional text that would limit their applicability to specified circumstances. (e.g., Portion control should be included as
part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy
intake and weight loss).
Conclusion Grading Table
Strength of
Evidence Elements

Grade I

Grade II

Grade III

Grade IV

Good/Strong

Fair

Limited/Weak

Expert Opinion Only

Grade V
Grade Not
Assignable

Quality
Scientific
rigor/validity
l

Considers
design and
execution
l

Studies of strong design for

question

Studies of strong
design for question
with minor
methodological
concerns

Free from design flaws, bias

and execution problems

OR

Studies of weak design for No studies available

answering the question
Conclusion based on usual
OR
practice, expert consensus,
clinical experience, opinion,
Inconclusive findings due
or extrapolation from basic
to design flaws, bias or
research
execution problems

No evidence
that pertains to
question being
addressed

Only studies of
weaker study design
for question
Consistency
Of findings across
studies

Quantity
Numberof
studies
l

Numberof
subjects in
studies
l

Findings generally consistent in

direction and size of effect or
degree of association, and
statistical significance with
minor exceptions at most

One to several good quality

studies
Large number of subjects
studied

OR

OR

Consistency with
minor exceptions
across studies of
weaker designs

Single study unconfirmed

by other studies

Several studies by
independent
investigators

Limited number of studies

Doubts about
adequacy of sample
Studies with negative results
size to avoid Type I
having sufficiently large sample
and Type II error
size for adequate statistical
power

Clinical Impact

Studied outcome relates

Importanceof directly to the question
studies outcomes Size of effect is clinically
meaningful
l Magnitudeof
l

effect

Inconsistency among Unexplained inconsistency

results of studies with among results from
strong design
different studies

Some doubt about

Studied outcome is an
the statistical or
intermediate outcome or
clinical significance of surrogate for the true
effect
outcome of interest

To population of
interest

NA

Unsubstantiated by published Relevant studies

studies
have not been
done

Objective data unavailable

Indicates area
for future
research

Generalizability limited to
scope of experience

NA

OR

Significant (statistical)
difference is large

Generalizability

Low number of subjects

studied and/or inadequate
sample size within studies

Conclusion supported solely

by statements of informed
nutrition or medical
commentators

Size of effect is small or

lacks statistical and/or
clinical significance

Studied population,
Minor doubts about
intervention and outcomes are generalizability
free from serious doubts about
generalizability

Serious doubts about

generalizability due to
narrow or different study
population, intervention or
outcomes studied

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to
evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading
system to this current version.

Criteria for Recommendation Rating

Statement

Definition

Implication for Practice

Rating

Strong

A Strong recommendation means that the workgroup believes that the benefits
of the recommended approach clearly exceed the harms (or that the harms
clearly exceed the benefits in the case of a strong negative recommendation),

Practitioners should follow a Strong recommendation

unless a clear and compelling rationale for an
alternative approach is present.

This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to
evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading
system to this current version.

Criteria for Recommendation Rating

Statement

Definition

Implication for Practice

Rating

Strong

A Strong recommendation means that the workgroup believes that the benefits
of the recommended approach clearly exceed the harms (or that the harms
clearly exceed the benefits in the case of a strong negative recommendation),
and that the quality of the supporting evidence is excellent/good (grade I or
II).* In some clearly identified circumstances, strong recommendations may be
made based on lesser evidence when high-quality evidence is impossible to
obtain and the anticipated benefits strongly outweigh the harms.

Practitioners should follow a Strong recommendation

unless a clear and compelling rationale for an
alternative approach is present.

Fair

A Fair recommendation means that the workgroup believes that the benefits
Practitioners should generally follow a Fair
exceed the harms (or that the harms clearly exceed the benefits in the case of a recommendation but remain alert to new information
negative recommendation), but the quality of evidence is not as strong (grade II and be sensitive to patient preferences.
or III).* In some clearly identified circumstances, recommendations may be made
based on lesser evidence when high-quality evidence is impossible to obtain and
the anticipated benefits outweigh the harms.

Weak

A Weak recommendation means that the quality of evidence that exists is

suspect or that well-done studies (grade I, II, or III)* show little clear
advantage to one approach versus another.

Practitioners should be cautious in deciding whether

to follow a recommendation classified as Weak, and
should exercise judgment and be alert to emerging
publications that report evidence. Patient preference
should have a substantial influencing role.

Consensus

A Consensus recommendation means that Expert opinion (grade IV)* supports

the guideline recommendation even though the available scientific evidence did
not present consistent results, or controlled trials were lacking.

Practitioners should be flexible in deciding whether to

follow a recommendation classified as Consensus,
although they may set boundaries on alternatives.
Patient preference should have a substantial
influencing role.

Insufficient
Evidence

An Insufficient Evidence recommendation means that there is both a lack of

pertinent evidence (grade V)* and/or an unclear balance between benefits and
harms.

Practitioners should feel little constraint in deciding

whether to follow a recommendation labeled as
Insufficient Evidence and should exercise judgment
and be alert to emerging publications that report
evidence that clarifies the balance of benefit versus
harm. Patient preference should have a substantial
influencing role.

*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV
signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the
conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see
chart above) to a recommendation.
Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice
Guideline, Pediatrics. 2004;114;874-877.

Clinical Algorithm(s)
Algorithms are provided in the original guideline document for:
l

ChronicKidneyDisease(CKD)NutritionGuideline

CKDNutritionAssessment

CKDNutritionDiagnosis

CKDNutritionIntervention

CKDNutritionMonitoringandEvaluation

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
The guideline contains conclusion statements that are supported by evidence summaries and evidence worksheets. These
resources summarize the important studies (randomized controlled trials [RCTs], clinical trials, observational studies,
cohort and case-control studies) pertaining to the conclusion statement and provide the study details.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
Aprimarygoalofimplementingtheserecommendationsincludesimprovingaperson'sabilitytoachieveoptimal
nutrition through healthful food choices and physically active lifestyle.
l

Althoughcostsofmedicalnutritiontherapy(MNT)sessionsandreimbursementvary,MNTisessentialforimproved
outcomes. MNT education can be considered cost effective when considering the benefits of nutrition interventions on
the onset and progression of comorbidities versus the cost of the intervention.
l

Potential Harms
Risk/Harm Considerations
When using these recommendations:
l

Reviewthepatient'sage,socioeconomicstatus,culturalissues,healthhistory,andotherhealthconditions.

Considerreferraltoabehavioralspecialistifpsychosocialissuesareaconcern.

Considerareferraltosocialservicestoassistpatientswithfinancialarrangementsifeconomicissuesareaconcern.

the onset and progression of comorbidities versus the cost of the intervention.
Potential Harms
Risk/Harm Considerations
When using these recommendations:
l

Reviewthepatient'sage,socioeconomicstatus,culturalissues,healthhistory,andotherhealthconditions.

Considerreferraltoabehavioralspecialistifpsychosocialissuesareaconcern.

Considerareferraltosocialservicestoassistpatientswithfinancialarrangementsifeconomicissuesareaconcern.

Useclinicaljudgmentinapplyingtheguidelineswhenevaluatingadultswithchronickidneydisease.

In addition to the above, a variety of barriers may hinder the application of these recommendations:
Lowerproteinandenergyintakescanleadtohypoalbuminemia,malnutrition,lossofleanbodymassand
unintentional weight loss.
l

Forchronickidneydisease(CKD)patientswithhypophosphatemiaorhyperphosphatemia,theregistereddietitian
(RD) should be aware that protein-controlled diets are typically lower in phosphorus content and therefore protein
intake may affect phosphorus management. Hypophosphatemia and hyperphosphatemia are associated with increased
morbidity and mortality.
l

TheRDshouldbeawareoftherisksofhypercalcemia,suchassofttissuecalcification,alteredmentalstatus,
tetany, cardiac events and other adverse effects.
l

Oralironsupplementationmayresultingastrointestinaldistressandlackofadherencetoregime.Ironabsorption
may be impaired by other medications, including phosphate binders, other iron and supplements.
l

ExcessiveintakeofvitaminCmayresultinhyperoxalosisandcontributetotheformationofcalciumoxalatekidney
stones.
l

Intensivetreatmentofhyperglycemiamayresultinmorefrequentepisodesofhypoglycemia.

Anutritionprescriptionthatistoohighortoolowinsodiummayresultinadverseoutcomes.

Thedietitianshouldbeawarethatfishoiltherapyprovidedatthelevelsgiveninthestudiescanaffecttheability
of the blood to coagulate and may be additive to the effects of anticoagulant therapy. Patient tolerance, adherence or
allergies may be factors in maintaining a fish oil supplementation regimen.
l

Beforebeginningaprogramofphysicalactivitymorevigorousthanbriskwalking,individualswithCKDshouldbe
assessed for conditions that might be associated with an increased risk of cardiovascular disease and other physical
conditions that may be adversely affected. Intense physical activity in adults with CKD may contribute to disability or
death, thus consultation with a physician prior to beginning an exercise program should be recommended.
l

Intakesofmultivitaminsupplementationabove100%ofthedietaryreferenceintakes(DRI)foranindividualmay
result in adverse effects.
l

Anutritionprescriptionthatistoohighortoolowinpotassiummayresultinadverseoutcomes.

Contraindications
Contraindications
Bone density assessment may be contraindicated in pregnancy.

Qualifying Statements
Qualifying Statements
ThisAmericanDieteticAssociationEvidence-Based Nutrition Practice Guideline is meant to serve as a general
framework for handling clients with particular health problems. It may not always be appropriate to use these nutrition
practice guidelines to manage clients because individual circumstances may vary. For example, different treatments may
be appropriate for clients who are severely ill or who have co-morbid, socioeconomic, or other complicating conditions.
The independent skill and judgment of the health care provider must always dictate treatment decisions. These
nutrition practice guidelines are provided with the express understanding that they do not establish or specify particular
standards of care, whether legal, medical, or other.
l

Evidence-based nutrition practice guidelines are developed to help registered dietitans, practitioners, patients,
families, and consumers make shared decisions about health care choices in specific clinical circumstances. If properly
developed, communicated and implemented, guidelines can improve care. While they represent a statement of
promising practice based on the latest available evidence at the time of publishing, they are not intended to overrule
professional judgment. Rather, they may be viewed as a relative constraint on individual clinician discretion in a
particular clinical circumstance.
l

Thisguidelinerecognizestheroleofpatientandfamilypreferencesforpossibleoutcomesofcare,whenthe
appropriateness of a clinical intervention involves a substantial element of personal choice or values.
l

Clinicaljudgmentiscrucialintheapplicationoftheseguidelines.Carefulconsiderationshouldbegiventothe
application of these guidelines for patients with significant medical co -morbidities.
l

Implementation of the Guideline

Description of Implementation Strategy
Description of Implementation Strategy
The publication of this guideline is an integral part of the plans for getting the American Dietetic Association Medical
Nutrition Therapy (ADA MNT) evidence-based recommendations on chronic kidney disease (CKD) to all dietetics
practitioners engaged in teaching about or researching this topic. National implementation workshops at various sites
around the country and during the ADA Food Nutrition Conference Expo (FNCE) are planned. Additionally, there are
recommended dissemination and adoption strategies for local use of the ADA CKD Evidence-Based Nutrition Practice
Guideline.
The guideline development team recommended multi-faceted strategies to disseminate the guideline and encourage its

Description of Implementation Strategy

Description of Implementation Strategy
The publication of this guideline is an integral part of the plans for getting the American Dietetic Association Medical
Nutrition Therapy (ADA MNT) evidence-based recommendations on chronic kidney disease (CKD) to all dietetics
practitioners engaged in teaching about or researching this topic. National implementation workshops at various sites
around the country and during the ADA Food Nutrition Conference Expo (FNCE) are planned. Additionally, there are
recommended dissemination and adoption strategies for local use of the ADA CKD Evidence-Based Nutrition Practice
Guideline.
The guideline development team recommended multi-faceted strategies to disseminate the guideline and encourage its
implementation. Management support and learning through social influence are likely to be effective in implementing
guidelines in dietetic practice. However, additional interventions may be needed to achieve real change in practice
routines.
Implementation of the guideline will be achieved by announcement at professional events, presentations and training.
Some strategies include:
l

National and local events: State dietetic association meetings and media coverage will help launch the guideline.

Local feedback adaptation: Presentation by members of the work group at peer review meetings and opportunities
for continuing education units (CEUs) for courses completed
l

Education initiatives: The guideline and supplementary resources will be freely available for use in the education
and training of dietetic interns and students in approved Commission on Accreditation of Dietetics Education (CADE)
programs.
l

Champions: Local champions will be identified and expert members of the guideline team will prepare articles for
publications. Resources will be provided that include PowerPoint presentations, full guidelines and pre-prepared case
studies.
l

Practical Tools: Some of the tools that will be developed to help implement the guideline include specially-designed
resources, such as clinical algorithms, slide presentations, training and toolkits.
l

Specific distribution strategies include:

Publication in full: The guideline is available electronically at the ADA Evidence Analysis Library website
(www.adaevidencelibrary.com ) and announced to all ADA Dietetic Practice Groups. The ADA Evidence Analysis Library
will also provide downloadable supporting information and links to relevant position papers.
Implementation Tools
Clinical Algorithm
Quick Reference Guides/Physician Guides
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Dietetic Association. Chronic kidney disease evidence-based nutrition practice guideline. Chicago (IL): American
Dietetic Association; 2010 Jun. Various p. [205 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2002 May (revised 2010 Jun)
Guideline Developer(s)
Academy of Nutrition and Dietetics - Professional Association
Source(s) of Funding
American Dietetic Association
Guideline Committee
American Dietetic Association Chronic Kidney Disease (CKD) Expert Work Group
Composition of Group That Authored the Guideline
Work Group Members: Jessie Pavlinac, MS, RD, CSR, LD, Chair; Arianna Aoun, MS, RD, CSR, LD; Laura Byham-Gray, PhD,
RD; Carolyn Cochran, MS, RD, LD, CDE; Barbara Hutson, RD, LD; Joni Pagenkemper, MS, MA, RD, LMNT, CDE
Financial Disclosures/Conflicts of Interest

Guideline Committee
American Dietetic Association Chronic Kidney Disease (CKD) Expert Work Group
Composition of Group That Authored the Guideline
Work Group Members: Jessie Pavlinac, MS, RD, CSR, LD, Chair; Arianna Aoun, MS, RD, CSR, LD; Laura Byham-Gray, PhD,
RD; Carolyn Cochran, MS, RD, LD, CDE; Barbara Hutson, RD, LD; Joni Pagenkemper, MS, MA, RD, LMNT, CDE
Financial Disclosures/Conflicts of Interest
In the interest of full disclosure, American Dietetic Association (ADA) has adopted the policy of revealing relationships
workgroup members have with companies that sell products or services that are relevant to this topic. Workgroup
members are required to disclose potential conflicts of interest by completing the ADA Conflict of Interest Form. It should
not be assumed that these financial interests will have an adverse impact on the content, but they are noted here to fully
inform readers. Users of the evidence analysis library may assume that only work group members listed below have
potential conflicts of interest to disclose.
None of the work group members disclosed potential conflicts of interest.
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Dietetic Association. Chronic kidney disease (non-dialysis) medical
nutrition therapy protocol. Chicago (IL): American Dietetic Association; 2002 May. Various p.
Guideline Availability
Electronic copies: Available from the American Dietetic Association Web site .
Availability of Companion Documents
The following are available:
AmericanDieteticAssociation(ADA)chronickidneydisease(CKD)evidence-based nutrition practice guideline.
Executive summary of recommendations. Chicago (IL): American Dietetic Association. 2010. Electronic copies: Available
from the ADA Web site .
l

ADAchronickidneydisease(CKD)evidence-based nutrition practice guideline presentation. Slide set. 2010. 64 p.

Chicago (IL): American Dietetic Association. Electronic copies: Available for purchase from the ADA Web site .
l

Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI on April 29, 2003. The information was verified by the guideline developer on
August 6, 2003. This summary was updated by ECRI on January 29, 2007, following the U.S. Food and Drug
Administration (FDA) advisory on erythropoiesis stimulating agents. This summary was updated by ECRI Institute on July
9, 2007, following the FDA advisory on erythropoiesis stimulating agents. This summary was updated by ECRI Institute on
December 16, 2010.
Copyright Statement
The American Dietetic Association encourages the free exchange of evidence in nutrition practice guidelines and promotes
the adaptation of the guidelines for local conditions. However, please note that guidelines are subject to copyright
provisions. To replicate or reproduce this guideline, in part or in full, please obtain agreement from the American Dietetic
Association. Please contact Kari Kren at kkren@eatright.org for copyright permission.
When modifying the guidelines for local circumstances, significant departures from these comprehensive guidelines should
be fully documented and the reasons for the differences explicitly detailed.

Disclaimer
NGC Disclaimer
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on this site.
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Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine
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NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or
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commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.

effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and
opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC,
AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.