Guidelines and protocols in Nephrology. _______________________________________

All Corona v (with spike protein) attachs to ace on the surface of type2 pneumocytes (ACE2), thus enters the cell and kill. ACEI blocks the ACE, and thus prevents cv entry, protective role. Advisory by current literature is to continue ACEI in infected persons.

12. Transplant

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5. KDIGO CKD DIET

2021 Updated KDOQI Clinical Practice Guidelines for Nutritional Management in CKD

Chronic kidney disease (CKD) puts the patients at an increased risk of nutritional and metabolic abnormalities. These disorders include protein-energy wasting (PEW), obesity, nutrient deficiencies, undesirable accumulation of electrolytes, and metabolic waste products. In majority of patients, optimal nutrition can successfully prevent and/or minimize the complications and also reduce the risk of unfavorable outcomes. Therefore, clinical practice guidelines are crucial for providing assistance to the clinicians to optimize patient care.

The Kidney Foundation Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in CKD: 2021 Update was developed as a joint effort by National Kidney Foundation and the Academy of Nutrition and Dietetics. These guidelines are designed to aid the assessment and management of nutritional assessments in CKD.1-3

Intervention recommendations1-5

Guideline 1:

Nutritional assessment recommendations:

DEXA is indicated as the gold standard for anthropometric measurement of body composition.Subjective global assessment (SGA) and malnutrition inflammation score (MIS) should be considered for assessment of nutritional status.Biochemical markers should not be interpreted in isolation to assess nutritional status since they are influenced by other factors in patients with CKD.Disease-specific predictive resting energy expenditure equations for patients on maintenance dialysis is encouraged.During assessment of dietary intake needs, factors beyond food intake such as knowledge, beliefs, attitudes, behavior, and access to food as well as psychological and cognitive aspects should be taken into consideration to effectively plan nutrition interventions in patients with CKD. Further research into development of risk prediction models using multiple nutritional markers, determining the effects of various nutritional interventions on nutritional markers and whether changes in values of a nutritional marker correlate with outcomes as a marker of efficacy is encouraged.

Guideline 2 and 3:

Medical Nutrition Therapy and Energy and Protein Recommendations:

The recommendation on medical nutrition therapy (MNT) encourages collaborative approach by the health-care team for optimization of the nutritional care by tailoring it to the individuals’ needs, nutritional status, and comorbid conditions.Low-protein diet (0.55–0.6 or 0.28–0.43 g/kg/day with keto-acid analogs) is recommended for non-diabetic and metabolically stable patients with stages 3 and 4 CKD.A more modest dietary protein restriction (0.6– 0.8 g/kg/day) is suggested for patients with diabetic kidney disease.Energy intake (25–35 kcal/kg/day) is recommended based on age, sex, level of physical activity body composition, weight status goals, and concurrent illnesses for patients with CKD.

Guideline 4:

Nutritional supplementation:

The updated guidelines suggest different types and routs of nutritional supplementation such as Oral, enteral, and IDPN along with strategies for prevention of dialysis induced catabolism and interventions to treat PEW in patients with CKD stages 3–5 and maintenance dialysis patientsThe consecutive steps to be taken in CKD patients with PEW or at risk of PEW include dietary counselling, a 3-month trial oral nutritional supplements and enteral tube feeding, if patients suffer from chronically inadequate intake and when the protein and energy requirement cannot be attained by counselling and oral nutritional supplement.Feeding through the gastrointestinal route should be preferred as long as possible and total parenteral nutrition or intradialytic parenteral nutrition may be considered as an option to administer nutrients if the enteral route fails.

Guideline 5:

Micronutrients:

Micronutrients assessment is recommended for diets of patients with CKD.Additionally, administration of vitamins and trace elements viz., Folic acid, Vitamin C (Ascorbic acid), Vitamin D, Vitamin E, Vitamin A, Vitamin K, Trace minerals – selenium and zinc is recommended under these updated guidelines.

Guideline 6:

Electrolytes:

Disturbances in mineral metabolism and acid-base homeostasis occur early in the course of CKD and are associated with a number of complications of the disease.
Therefore, clinicians should consider strategies for reduction of acid load in patients with CKD.Management of dietary components is crucial for prevention and treatment of electrolyte and acid-base disorders. Dietary components such as calcium, phosphorus, potassium and sodium are recommended for managing fluid retention and controlling blood pressure.

Conclusion

These updated guidelines regarding the management of nutritional and metabolic aspects of kidney disease will contribute in better dietary management of patients with chronic kidney diseases.

Key messages

Medical Nutrition Therapy (MNT) encouragescollaborative approach by the health-care team to optimize the nutritional care by tailoring it to the individuals’ needs, nutritional status, and comorbid conditions.Protein, vitamins, trace minerals and electrolytes should be added in the diet for patients with CKD post-assessment.