NKF-DOQI Guidelines on Nutrition To Be Released in August

The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines on Nutrition are set to be released for public review this month. The guidelines are a follow-up to those related two years ago covering hemodialysis adequacy, peritoneal dialysis adequacy, vascular access, and the treatment of anemia of chronic renal failure.

Because of the differing nutritional requirements of adults and children on chronic dialysis, the new guidelines have been segmented to address the specific needs of both groups. The guidelines also, for the most part, separately address the differing nutritional considerations of hemodialysis and peritoneal dialysis patients.

As reported by the NKF, the primary focus of the new guidelines is on dietary protein and energy requirements, as well as on methods of nutritional assessment. Recommendations found in the guidelines for protein and energy intake include the following:

• Optimal protein intake for maintenance adult hemodialysis patients is 1.2 g/kg body weight per day. Children on hemodialysis should have their initial dietary protein intake based on the recommended dietary allowance (RDA) for their age group, plus an additional increment as specified in the guidelines.
• Optimal protein intake for chronic peritoneal dialysis patients is 1.3 g/kg body weight per day. Optimal intake for children is based on the RDA plus an additional 0.7-0.8 g/kg/day.
• Optimal energy intake (i.e., energy from fat and carbohydrates) for adult dialysis patients < 60 years old is 35 kcal/kg/day. For patients over the age of 60, optimal intake is 30-35 kcal/kg/day. Intake of calories from peritoneal dialysis fluid should be taken into account when considering total energy intake for those patients. Energy intake in children on both hemodialysis and peritoneal dialysis should initially be prescribed at the RDA level for chronological age, with later modifications being made depending upon the child's response.

Regarding the measurement of nutritional status, the NKF-DOQI Clinical Practice Guidelines on Nutrition recommend the following tools for use with adult dialysis patients:

• Normalized protein equivalent of nitrogen appearance (nPNA), a measure derived from the daily net generation of urea normalized to body weight.
• Serum albumin and serum prealbumin levels, a measure of protein in the blood.
• Subjective global assessment, which is a set of observations based on a patient's symptoms and on physical examination.
• Anthropometry, a measure of skinfold thickness and other aspects of body composition.
• Dual X-ray absorptiometry, an X-ray technique measuring the components of body mass.

The pediatric guidelines additionally cover nutritional supplements for children who are not growing normally due to kidney failure, as well as vitamin and mineral requirements, performance of appropriate nutritional measurements, nutrition for hospitalized children on dialysis, and evaluation for human growth hormone.

Said Joel Kopple, MD, the new NKF president and chairman of the NKF-DOQI nutrition workgroup:"Malnutrition is a high predictor of mortality in maintenance dialysis patients. We anticipate that the publication of these guidelines will lead to an improvement in the nutritional status of dialysis patients and, hopefully, boost their overall health, quality of life, and survival rates."

The development of the NKF-DOQI Clinical Practice Guidelines on Nutrition are being funded by an unrestricted grant from Sigma-Tau Pharmaceuticals, Inc., a worldwide leader in the carnitine and metabolic research. The previous guidelines were funded by Amgen, Inc.

To obtain copies of the draft nutrition guidelines or any of the previous guidelines, contact the NKF at 30 E. 33rd St., New York, NY; 800/622-9010; 212/889/2210; Fax 212/389-9261; www.kidney.org.