Unleashing the Power of Renal Nutrition in Value-Based Models of Kidney Care Choices: Leveraging Dietitians’ Expertise and Medical Nutrition Therapy to Delay Dialysis Initiation

Abstract

Value-based models of kidney care are upstream expansions of the pre-existing end-stage renal disease (ESRD) payment models in that they encompass medical care of persons with far-advanced chronic kidney disease (CKD) not yet on dialysis. These patient-centered models are paradigm shifting because they provide rewards, including financial incentives for delaying dialysis initiation in patients with late-stage (Stages 4 and 5) CKD when the estimated glomerular filtration rate (eGFR) is below 30 mL/min/1.73 m2Kalantar-Zadeh K. Moore L.W. Engaging nutrition and diet for Primary, secondary, and Tertiary prevention of kidney disease: the World kidney Day 2020.J Ren Nutr. 2020; 30: 89-91Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, which is in sharp contradistinction to traditional ESRD models of earlier dialysis therapy transition. The value-based models are within the “Kidney Care Choices” (KCC) platform developed by the Center for Medicare and Medicaid Services (CMS) of the United States Department of Health and Human Services as an expansion of the pre-existing Comprehensive ESRD Care.1Jain G. Weiner D.E. Value-based care in Nephrology: the kidney care choices model and other reforms.Kidney360. 2021; 2: 1677-1683Crossref PubMed Google Scholar Besides adding strong financial incentives to healthcare providers to delay the onset of dialysis, the CMS value-based models also incentivize earlier kidney transplantation and encourage home-based dialysis when renal replacement therapy is indicated, as opposed to little prevention of disease progression and an unplanned start to in-center hemodialysis treatment in traditional ESRD models.2Kalantar-Zadeh K. Moore L.W. Engaging nutrition and diet for Primary, secondary, and Tertiary prevention of kidney disease: the World kidney Day 2020.J Ren Nutr. 2020; 30: 89-91Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Currently, the KCC models consist of four payment options, including one payment option under the Kidney Care First (KCF) and three under the Comprehensive Kidney Care Contracting (CKCC), i.e., Graduated, Professional, and Global CKCC options.1Jain G. Weiner D.E. Value-based care in Nephrology: the kidney care choices model and other reforms.Kidney360. 2021; 2: 1677-1683Crossref PubMed Google Scholar As to how to delay dialysis initiation, there has been an exponential emergence of kidney care companies that announce expertise in doing so under value-based models. Some of the approaches presented are vague and include computerized models using artificial intelligence to postpone dialysis with the varying engagement of patients and their care partners.3Moore L.W. Wang A.Y.M. Kalantar-Zadeh K. Global kidney nutrition care and health Literacy: Overcoming the Disparities in renal nutrition Service Capacity and education.J Ren Nutr. 2022; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar According to CMS, the patient should be a key component of the KCC model design, including across KCF and CKCC options. Persons with far-advanced CKD may be better prepared for kidney care choices if they actively participate in shared decision-making in the context of practicing health equity and patient activation. An overarching approach includes both pharmacologic therapies and diet and lifestyle modifications in the form of integrated multimodal strategies, embraced by patients and their care partners with the goal of living well with kidney disease.4Kalantar-Zadeh K. Kam-Tao Li P. Tantisattamo E. et al.Living well with kidney disease by patient and Carepartner Empowerment: kidney health for Everyone Everywhere.J Ren Nutr. 2021; 31: 233-238Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The most likely nonpharmacologic interventions to be employed under the value-based models include practicing patient-centered nutritional management of CKD that is evidence-based and pragmatic and can slow disease progression and control uremia.2Kalantar-Zadeh K. Moore L.W. Engaging nutrition and diet for Primary, secondary, and Tertiary prevention of kidney disease: the World kidney Day 2020.J Ren Nutr. 2020; 30: 89-91Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,5Moore L.W. Kalantar-Zadeh K. Implementing the "advancing American kidney health initiative" by Leveraging nutritional and dietary management of kidney patients.J Ren Nutr. 2019; 29: 357-360Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar As a foundation, this strategy should include using low and very low protein diets, i.e., dietary protein intake of 0.6-08 g/kg/day and <0.6 g/kg/day, respectively. An approach to this strategy is derived from plant-dominant (PLADO) diet regimens where >50% of the protein source is from plant-based proteins, and that is implemented in the form of medical nutrition therapy (MNT) by trained dietitians.6Kalantar-Zadeh K. Mattix-Kramer H.J. Moore L.W. Culinary medicine as a core component of the medical nutrition therapy for kidney health and disease.J Ren Nutr. 2021; 31: 1-4Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,7Rhee C.M. Kalantar-Zadeh K. Moore L.W. Medical nutrition therapy for diabetic kidney disease.J Ren Nutr. 2021; 31: 229-232Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The PLADO-based MNT should be the cornerstone of the integrated multimodal approach to delay dialysis initiation, while it will benefit from adjunct pharmacotherapy for fluid management, acidosis and anemia corrections, management of potassium and phosphorus load, and treating unpleasant symptoms of uremia such as pruritus and gastrointestinal symptoms.8Kalantar-Zadeh K. Moore L.W. Improving Muscle strength and preventing sarcopenia and cachexia in chronic kidney disease and transplanted patients by physical activity and exercise.J Ren Nutr. 2019; 29: 465-466Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar In addition, continued research on underlying mechanisms of CKD progression relative to nutrition with the goal of nutritional treatment strategies to modulate gut health and microbiota, uremic toxin production and micronutrient provision will likely impact the outcomes of patients with CKD, including in the post-COVID pandemic era.9Joshi S. Moore L.W. Kalantar-Zadeh K. The Future of nutrition in kidney disease: plant-based diets, gut Microbiome, and beyond.J Ren Nutr. 2021; 31: 97-99Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Given concerns about the risk of protein-energy wasting, secondary sarcopenia, and cachexia that may ensue in far-advanced CKD if there is inadequate nutrition, the PLADO-based low and very low protein diets may benefit from nutritional supplementation, including essential amino acids and/or keto-analogs of amino acids.10Kalantar-Zadeh K. Joshi S. Schlueter R. et al.Plant-dominant low-protein diet for conservative management of chronic kidney disease.Nutrients. 2020; 12: 1931Crossref PubMed Scopus (51) Google Scholar, 11Ko G.J. Kalantar-Zadeh K. How important is dietary management in chronic kidney disease progression? A role for low protein diets.Korean J Intern Med. 2021; 36: 795-806Crossref PubMed Scopus (4) Google Scholar, 12Kalantar-Zadeh K. Rhee C.M. Joshi S. Brown-Tortorici A. Kramer H.M. Medical nutrition therapy using plant-focused low-protein meal plans for management of chronic kidney disease in diabetes.Curr Opin Nephrol Hypertens. 2022; 31: 26-35Crossref PubMed Scopus (3) Google Scholar However, clinical trials of low- and very-low protein diets and meta-analyses of these trials have been inconsistent.13Kalantar-Zadeh K. Moore L.W. Does kidney Longevity mean Healthy vegan food and less Meat or is Any low-protein diet Good Enough?.J Ren Nutr. 2019; 29: 79-81Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Another challenge is that half or a higher proportion of persons with advanced CKD have diabetes or suffer from obesity and metabolic syndrome, where obese sarcopenia is more likely and for which higher dietary protein intake is traditionally recommended. Higher protein intake may worsen CKD progression and uremic symptoms by increasing the level of nitrogenous end-products of amino acids leading to higher circulating levels of uremic toxins;11Ko G.J. Kalantar-Zadeh K. How important is dietary management in chronic kidney disease progression? A role for low protein diets.Korean J Intern Med. 2021; 36: 795-806Crossref PubMed Scopus (4) Google Scholar,14Cho E. Choi S.J. Kang D.H. Kalantar-Zadeh K. Ko G.J. Revisiting glomerular hyperfiltration and examining the concept of high dietary protein-related nephropathy in athletes and bodybuilders.Curr Opin Nephrol Hypertens. 2022; 31: 18-25Crossref PubMed Scopus (1) Google Scholar,15Ko G.J. Rhee C.M. Kalantar-Zadeh K. Joshi S. The Effects of high-protein diets on kidney health and Longevity.J Am Soc Nephrol. 2020; 31: 1667-1679Crossref PubMed Scopus (37) Google Scholar moreover, individual disease states may benefit from distinct nutritional interventions given data supporting ketogenic diet for polycystic kidney disease, gluten-free diet for IgA nephropathy, and lower glycemic index foods for diabetic kidney disease.12Kalantar-Zadeh K. Rhee C.M. Joshi S. Brown-Tortorici A. Kramer H.M. Medical nutrition therapy using plant-focused low-protein meal plans for management of chronic kidney disease in diabetes.Curr Opin Nephrol Hypertens. 2022; 31: 26-35Crossref PubMed Scopus (3) Google Scholar However, engaged dietitians equipped with well-designed dietary management models can implement patient-centered MNT strategies using telenutrition and other educational and monitoring modalities.9Joshi S. Moore L.W. Kalantar-Zadeh K. The Future of nutrition in kidney disease: plant-based diets, gut Microbiome, and beyond.J Ren Nutr. 2021; 31: 97-99Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Nutritional status can be watched closely by means of screening tools, including the malnutrition-inflammation score (MIS) and MIS-based algorithms can be developed to minimize the risk of protein-energy wasting from advanced uremia. Healthcare providers, including nephrologists and kidney care companies can partner for better education and research and improved understanding of the utility and implementation of nutritional managements strategies using principles of culinary medicine-based MNT and addressing the need of patients and care partners with the goal of living well with kidney disease.3Moore L.W. Wang A.Y.M. Kalantar-Zadeh K. Global kidney nutrition care and health Literacy: Overcoming the Disparities in renal nutrition Service Capacity and education.J Ren Nutr. 2022; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In this issue of the Journal, Russell et al.16Russell 3rd, C.R. Zigan C. Wozniak K. Soni K. Hill Gallant K.M. Friedman A.N. A Systematic Review and Qualitative Analysis of existing dietary mobile Applications for people with chronic kidney disease.J Ren Nutr. 2022; 32: 382-388Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined the utility of mobile diet apps used for the nutritional management of CKD available on the App Store and Google Play Store, using such selection criteria as CKD stage specificity, adjustment for individual dietary needs, tracking nutrient intake, patient data accessibility to clinicians, and inclusion of CKD-friendly recipes. The investigators found that these criteria were not consistently met and that none of the apps used the most contemporary nutrition guidelines for CKD. They also noted limitations with diet app usability, information accuracy, and the need for high-level e-literacy. Other issues identified included variable user costs, privacy and security concerns, and the inability of caregivers or family care partners to use apps to assist in patient care.16Russell 3rd, C.R. Zigan C. Wozniak K. Soni K. Hill Gallant K.M. Friedman A.N. A Systematic Review and Qualitative Analysis of existing dietary mobile Applications for people with chronic kidney disease.J Ren Nutr. 2022; 32: 382-388Abstract Full Text Full Text PDF Scopus (1) Google Scholar The value-based models provide unique opportunities to innovate and improve CKD diet apps for delaying dialysis initiation. Wong et al.17Wong M.M.Y. Renouf D. Zheng Y. Sheriff Z. Levin A. Nutritional status, nutritional Phenotypes, and oral nutritional supplement prescription Patterns among patients with non-dialysis chronic kidney disease in British Columbia.J Ren Nutr. 2022; 32: 414-422Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined data of 15,859 persons with nondialysis-dependent CKD in outpatient clinics in British Columbia, Canada, and found that 9% of them were prescribed oral nutritional supplements within a year of CKD clinic entry and that these patients exhibited lower baseline eGFR, body mass index, and serum albumin among others. The likelihood of oral nutritional supplement prescription increased by 32% for every unit increase in dietitian full-time equivalents per 1,000 CKD patients. Findings from this and similar studies may help better understand the needed dietitian workforce trajectory for successful and safe implementation of nutritional management of CKD to delay dialysis initiation under the value-based modes of kidney care. Okada et al.18Okada A. Yamana H. Yamaguchi S. et al.Effect of branched-chain amino acid infusion on in-hospital mortality of patients with hepatic encephalopathy and end-stage kidney disease: a Retrospective cohort study using a National Inpatient Database.J Ren Nutr. 2022; 32: 432-440Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined a cohort of 553 patients with renal failure and liver cirrhosis, including hepatic encephalopathy, and reported that 503 patients who received branched-chain amino acid infusion had 49% lower mortality than those who did not, including decreased in-hospital mortality in patients with Child-Pugh class. These data, too, may have implications for value-based models where nutritional management may include amino acid supplements. Stout et al.19Stout T.E. Lingeman J.E. Krambeck A.E. et al.A randomized trial Evaluating the Use of a smart water bottle to increase fluid intake in stone formers.J Ren Nutr. 2022; 32: 389-395Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined the utility of a smart water bottle to improve urine volume in a randomized trial of 85 stone-former subjects with <1.5 L/day fluid intake and found that use of a smart bottle was associated with greater increases in 24-hour urine volume and less difficulty remembering to drink. Brennan et al.20Brennan F. Dawson J. Brown M.A. A novel clinical tool for the management of taste changes in patients with chronic kidney disease: the chronic kidney disease Taste Plate.J Ren Nutr. 2022; 32: 483-488Abstract Full Text Full Text PDF Scopus (1) Google Scholar describe their CKD Taste Plate as a novel tool to assist clinicians with the management of taste alterations in CKD, given that perception of taste can affect dietary management of CKD. Bielopolski et al.21Bielopolski D. Wenziger C. Steinmetz T. Rozen Zvi B. Kalantar-Zadeh K. Streja E. Novel protein to phosphorous Ratio score predicts mortality in hemodialysis patients.J Ren Nutr. 2022; 32: 450-457Abstract Full Text Full Text PDF Scopus (1) Google Scholar developed and examined a novel metric that incorporates serum phosphorous and normalized protein catabolic rate, a surrogate of dietary protein intake, to examine the associations with mortality in 63,016 people of maintenance hemodialysis and report that the metric predicts mortality in people on dialysis, probably reflecting both nutrition and inflammation state independent of RKF. The metric enables better phosphorus monitoring, although adequate dietary protein intake is ensured and may improve the prediction of outcomes in the clinical setting. Fishbane et al.22Fishbane S. Charytan D.M. Chertow G.M. et al.Consensus-based recommendations for the management of hyperkalemia in the hemodialysis setting.J Ren Nutr. 2022; 32: e1-e14Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar discuss the challenges of controlling hyperkalemia in persons with advanced CKD such as ESRD based on the traditional dogma of avoiding potassium-rich foods that are mostly high fruits-and-vegetables diet. Given that PLADO diet regimens that may help delay dialysis under the value-based models may be considered high-potassium diets, the use of potassium binders as adjunct therapy may be a useful strategy. Accurate assessment of nutritional status can emerge as an important component of conservative management of patients with advanced CKD without dialysis.23Workeneh B.T. Kalantar-Zadeh K. Moore L.W. Progress in the Identification and management of protein-energy wasting and sarcopenia in chronic kidney disease.J Ren Nutr. 2021; 31: 335-339Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Ha et al.24Ha J.W. Pyo J.Y. Ahn S.S. Song J.J. Park Y.B. Lee S.W. Nutrition risk index score at Diagnosis can effectively predict poor Prognosis in patients with antineutrophil cytoplasmic antibody-associated vasculitis.J Ren Nutr. 2022; 32: 423-431Abstract Full Text Full Text PDF Scopus (1) Google Scholar studied nutritional risk index (NRI) score in 242 immunosuppressive drug-naive patients with antineutrophil cytoplasmic antibody-associated vasculitis and the association of this score with all-cause mortality and ESRD occurrence during follow-up of these patients. Delgado et al.25Delgado C. Chiang J.M. Kittiskulnam P. et al.Longitudinal assessment of body composition and its association with survival among Participants of the ACTIVE/ADIPOSE study.J Ren Nutr. 2022; 32: 396-404Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined changes in body composition over time and their association with survival in 325 adults receiving hemodialysis using whole-body bioimpedance spectroscopy at baseline and then at 12 and 24 months; they found that intracellular water, which was associated with greater survival, declined over time, whereas fat mass and extracellular water remained relatively stable and that higher extracellular water but not fat mass was associated with worse survival. Avesani et al.26Avesani C.M. Sabatino A. Guerra A. et al.A Comparative Analysis of nutritional assessment using global Leadership initiative on malnutrition versus subjective global assessment and malnutrition inflammation score in maintenance hemodialysis patients.J Ren Nutr. 2022; 32: 476-482Abstract Full Text Full Text PDF Scopus (2) Google Scholar examined the utility of their recently developed “Global Leadership Initiative on Malnutrition” against 7-point subjective global assessment (SGA) and MIS as reference standards in two cohorts of dialysis patients in Italy and Brazil and found that their new tool showed low agreement, sensitivity, and accuracy in identifying malnourished subjects by either SGA or MIS. Considering the high likelihood of wasting disorders in advanced CKD, the well-established 7-point SGA and MIS methods may be more useful in the clinical setting of monitoring patients who will be under the delay-dialysis protocols in the context of value-based models. Wu et al.27Wu I.W. Liao P.J. Ting M.K. Chen S.W. Yang N.I. Hsu K.H. Combination of thigh circumference and Indices of Central obesity helps predict incident chronic kidney disease: a 14-year Prospective cohort study using a three-dimensional body Laser scanner.J Ren Nutr. 2022; 32: 405-413Abstract Full Text Full Text PDF Scopus (1) Google Scholar studied the incidence of CKD in a cohort of 7,825 Taiwanese people who underwent 3-dimensional body surface scanning with an average follow-up of 14.3 years and found that while larger chest width and waist circumference are associated with higher CKD, body limb measurements, including larger thigh circumference predict the lower occurrence of CKD. Suzuki et al.28Suzuki Y. Matsuzawa R. Hoshi K. et al.Comparative Analysis of Simplified, Objective nutrition-associated markers in patients undergoing hemodialysis.J Ren Nutr. 2022; 32: 458-468Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined the utility of a modified creatinine index and geriatric nutritional risk index (GNRI) in 472 patients undergoing hemodialysis and their respective rates of change over a 1-year period and found that creatinine index at one timepoint and its trajectory had consistently stronger associations with clinical events than the GNRI in patients undergoing hemodialysis. This study further emphasizes the importance of risk screening using a marker of nutritional status in patients with advanced CKD and may have implications in the era of value-based models. Close monitoring of physical performance and functionality are of immense importance under the value-based models when delayed dialysis initiated is attempted. Reis et al.29Reis J.M.S. Alves L.S. Vogt B.P. According to revised EWGSOP sarcopenia Consensus Cut-Off points, low physical function is associated with nutritional status and quality of life in maintenance hemodialysis patients.J Ren Nutr. 2022; 32: 469-475Abstract Full Text Full Text PDF Scopus (3) Google Scholar examined the association of nutritional status using MIS and quality of life using SF-36 with physical function, according to the revised European Working Group on Sarcopenia in Older People in 77 dialysis patients. They employed handgrip strength, Short Physical Performance Battery, sit-to-stand test, and gait speed as physical function tests and found that poor nutritional status and quality of life are associated with low physical function. Wilkinson et al.30Wilkinson T.J. Gabrys I. Lightfoot C.J. et al.A Systematic Review of handgrip strength measurement in clinical and epidemiological studies of kidney disease: toward a standardized approach.J Ren Nutr. 2022; 32: 371-381Abstract Full Text Full Text PDF Scopus (2) Google Scholar identified 129 clinical and epidemiological studies in 35,192 persons with CKD examining the use of handgrip strength as an outcome. They report that the heterogeneous methodologies underscore the need to standardize HGS measurement and propose a comprehensive handgrip strength assessment protocol for use in CKD. Bennet et al.31Bennett P.N. Kohzuki M. Bohm C. et al.Global policy barriers and enablers to exercise and physical activity in kidney care.J Ren Nutr. 2022; 32: 441-449Abstract Full Text Full Text PDF Scopus (3) Google Scholar sought to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease, guided by the Behavior Change Wheel theoretical framework, in that 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The expert report includes recommendations targeting multiple stakeholders, including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders, and suggests that increasing physical activity, strength, fitness, and function may improve the lives of people living with kidney disease. Similarly, Barros et al.32Barros F.S. Pinheiro B.V. Ribeiro H.S. Rezende G.F. Lucinda L.M.F. Reboredo M.M. A strategy to improve the presence of exercise professionals in dialysis Units.J Ren Nutr. 2022; 32: 489-490Abstract Full Text Full Text PDF Scopus (2) Google Scholar advocate strategies that can enhance the presence of exercise professionals in dialysis clinics. Monitoring the physical performance of patients with far advanced CKD without dialysis initiation may become a critical task under the value-based models. In conclusion, the emergence of value-based models offers a unique opportunity to venture into the field of person-centered nutritional management of CKD without dialysis by using the power of upstream engagement of dietitians with expertise in kidney nutrition in the form of well-crafted MNT strategies based on Precision Nutrition and personalized diet plans, and inclusive of all stages of kidney disease33Kalantar-Zadeh K. Moore L.W. Precision nutrition and personalized diet plan for kidney health and kidney disease management.J Ren Nutr. 2020; 30: 365-367Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The core component of these MNT models is effective PLADO-derived low and very low protein diet regimens that can be supplemented with amino-acid or keto-analogs of amino acids to ensure safety and to minimize the risk of protein-energy wasting sarcopenia and cachexia. Nutritional screening tools such as MIS can help identify and preempt patients at risk of protein-energy wasting. When dialysis becomes necessary, it can start gradually in the form of incremental dialysis at home or center, along with the continuation of PLADO regimens on nondialysis days so that residual kidney function can longer be preserved. The MNT is the quintessential component of integrated multimodal approaches that are effective and safe, as well as feasible and inexpensive for the era of value-based kidney care models in lieu of the conventional dialysis treatment.