Nutrition in renal supportive care: Is it time to bend the rules?

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Renal Supportive Care (RSC) is commanding global attention. Increased interest demands critical appraisal of what we do and why we do it. Traditional renal replacement treatments may not be suitable for all people with advanced chronic kidney disease (CKD), and there has been increasing interest in providing an alternate pathway to manage and support these patients and their families. People living with CKD have been described as one of the most heavily burdened disease groups with quality of life (QoL) and symptom burden likened to that of malignant disease.1 Consequently, RSC must use the expertise of a multidisciplinary team to manage these patients appropriately. Across Australia, there have been both formal and informal introductions of the RSC pathway, incorporating a multidisciplinary team of renal and palliative care physicians, nursing staff, renal dietitians, social workers and other allied health professionals to manage the complexities of this patient group.
The rise of RSC has seen a paradigm shift in treatment goals, from prolonging life to a focus on patient‐centred care, QoL and symptom control.2 Common referrals to RSC services include those patients who are not suitable for, or chosen not to have dialysis, the elderly with multiple comorbidities, those on renal replacement therapies (dialysis and transplantation) suffering a high‐symptom burden requiring more specialized management and those who are withdrawing from dialysis requiring end‐of‐life care.1 Recent studies have shown the average survival for people managed on a conservative pathway is approximately 16–21 months, which is not substantially different to that of elderly patients on dialysis.2 Survival rates in this patient group challenge the common perception that conservative treatment is closely linked to terminal care and have strengthened the evidence for the benefits of a non‐dialysis RSC pathway.1 Appropriate nutritional care in RSC is vital to maintain patients' QoL, physical functioning and independence, reduce symptom burden and optimize nutritional status.
Dietary requirements for people with CKD are complex and can be a source of anxiety for patients and their families. Therefore in RSC, current nutrition management goals and strategies need to be re‐evaluated. Traditional diet advice in CKD has focused on prolonging life, preparing patients for dialysis and reducing the risk of secondary complications through strict electrolyte, fluid and macronutrient control. However, in the RSC setting, QoL and symptom burden should be the primary focus of nutritional management.
The role of dietitians is diverse and extends beyond the prevention and management of malnutrition. Nutritional management should be underpinned by a strong focus on patient‐centred care and QoL to align with the goals of RSC. In RSC, dietitians should focus on ensuring adequate nutrition and managing malnutrition, assisting in symptom control and supporting and educating patients, their families and support networks within the confines of a renal diet.1 Nutrition impact symptoms are common in end‐stage kidney disease and often amenable to nutrition interventions; however in clinical practice, these interventions are often under‐recognized, underused or poorly understood. Nutrition interventions can delay the onset of, and help manage, symptoms such as uraemic and hyperphosphatemic pruritus, peripheral oedema, taste changes, dry mouth, constipation and nausea when they occur. Symptom relief may take priority over control of biochemical parameters. Nutrition interventions should be positive and support other goals of patient‐centred care such as overcoming symptoms to enhance the enjoyment of food, promote healthy bowel function and support exercise interventions that may slow the decline of muscle wasting and frailty. In RSC, patients should be supported to make informed dietary choices. A patient may choose to maintain a degree of dietary restriction for symptom control, comfort or personal control, but they may also choose to relax dietary restrictions knowing the potential implications.
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