Chronic kidney disease and nutritional management: A look into the future

How does nutrition support CKD management?

Malnutrition is a common complication of CKD that significantly impacts the patient’s quality of life. The causes of malnutrition in CKD patients are multifaceted, from reduced absorption of nutrients and metabolic impairments due to reduced kidney function causing accumulation of waste products, to increased nutrient loss and energy wasting during dialysis. While non-dialyzed CKD patients are recommended to reduce the intake of protein (~0.6g/kg BW/d of high-biological value protein when adequate calories are given), phosphate, potassium and sodium, dialyzed CKD patients require up to 1.4g/kg BW/d and higher levels of energy and potassium.³ The prevalence of malnutrition increases as kidney function decreases.⁴

Optimized nutritional status in CKD patients is positively associated with better quality of life, lower risk of complications and reduced risk of malnutrition.^5,6,7 To manage CKD appropriately, early and regular screening for malnutrition and the continuous assessment of nutritional status in patients is therefore essential.

What is the impact of oral nutritional supplements (ONS) on nutritional status?

A recent study by Wong and team at the University of British Columbia assessed the association between ONS and nutritional status parameters in patients with non-dialysis CKD, specifically those with – or at high risk of – undernutrition/protein-energy wasting (PEW).⁸ Nutritional status parameters like BMI and serum albumin were evaluated in the two years prior to nutritional intervention (pre-ONS) and two years after the first ONS prescription (post-ONS). Across almost 4,000 patients, the study found that ONS prescription was associated with an improvement in nutritional status parameters. However, although the data is promising, it’s important to note that the observational design of Wong’s study meant that a causal link between ONS prescription and nutritional parameters could not be determined.

In addition, the study highlighted that specific patient phenotypes, such as those with subclinical inflammation and low BMI, appeared to have a more favorable response to ONS. Other factors such as the stage of CKD, the way it is managed (i.e. via dialysis vs non-dialysis) and the presence of complications must also be considered. A personalized nutritional care approach to CKD, as well as other conditions such as anemia and bone-mineral disorders, need to be considered to be able to successfully manage nutritional status and optimize patient care in these areas.

Patients on dialysis are at an even higher risk of malnutrition. Dialysis is a catabolic event that increases energy expenditure and protein breakdown while reducing protein synthesis (high prevalence of PEW), and can cause loss of water-soluble vitamins, minerals and other important nutrients, depending on the type of dialysis. Nutritional management and medical nutrition solutions therefore play an important role in meeting the specific nutritional requirements of these patients from the early stages onwards.  

What does CKD nutritional care and ONS availability look like on the global stage?

Although more and more randomized studies support the positive effects of nutritional care on the nutritional status of CKD patients⁹ and despite clinical nutrition guidelines published by ESPEN to support patients with CKD¹⁰, the availability and capacity of global kidney nutrition care is becoming a real barrier in progression. With over 850 million adults worldwide estimated to have CKD, this is not a localized health challenge.¹¹ To assess the scale of the issue, the Global Kidney Nutrition Care Atlas explored the global capacity of kidney nutrition services and ONS availability via a questionnaire administered among key kidney care stakeholders across 182 countries.¹²

The results of the survey emphasize that nutritional intervention is an important component of CKD management – helping to optimize CKD patients’ nutritional status and helping against PEW.^13,14 The study also revealed that there were significant global variations in the availability of specialized nutritional products, with more high-income countries reimbursing supplementation costs compared to low-income countries, where ONS prescriptions that are costly for patients are the norm in both inpatient and outpatient settings. Unsurprisingly, the practical cost barriers in many low- and lower middle-income countries are affecting how CKD patients are supported.

As well as access to ONS, successful nutrition intervention relies heavily on renal dietitians to deliver regular dietary counselling and monitoring too. Globally, only 48% of the 155 countries surveyed had dietitians to provide this specialized nutrition service.¹⁵ In addition, dietary counselling was unavailable in 65% of low- to middle-income countries and 41% of countries surveyed failed to provide formal assessments of nutrition status in kidney nutrition care. This highlights the significant gaps in nutritional care worldwide, especially in low- and lower middle-income regions.

What does the future look like for ONS in CKD patients?

It is clear that a significant joint global effort is needed to raise awareness of the importance of specialized nutrition assessment and to implement nutritional management initiatives that support CKD patient care.

In order to improve nutrition assessment and care in CKD patients, education and training programs are necessary to help support healthcare professionals with the required skills and knowledge, especially in resource-constrained situations. Specialized medical nutrition products must also be made readily available and reimbursed to allow specialized dietitians to implement optimal nutritional care.

A patient-focused approach for purpose-led innovation

At dsm-firmenich, we are passionate about tackling some of the world’s most challenging nutrition and health problems by raising the standard of nutritional care and supporting the health of populations worldwide. That’s why we take a targeted approach to medical nutrition innovation, enabling manufacturers to develop unique and appealing solutions that address the specific nutritional requirements of CKD patients.

To help fight malnutrition in patients and raise standards of care globally, dsm-firmenich is developing a series of science-backed concepts to be launched in 2022. Stay tuned to Talking Nutrition to be the first to find out when they’ve launched!

Learn more about how dsm-firmenich enables the development of purpose-led, targeted medical nutrition solutions.