PRACTICAL ASPECTS

National Kidney Foundation Dialysis Outcomes Quality Initiative: Implications for Renal Dietitians Linda McCann, RD, LD*

The Dialysis Outcomes Quality Initiative is sponsored by the National Kidney Foundation with the objective of improving patient survival, reducing patient morbidity, increasing efficiency of care, and improving the quality of life for all dialysis patients. This initiative brought interdisciplinary teams together to evaluate contemporary renal practice in five clinical areas including hemodialysis adequacy, peritoneal adequacy, anemia, vascular access, and nutrition. The purpose of this report is to provide a general overview of the guidelines and their potential implications for renal dietitians. It also serves as a challenge for renal dietitians to get involved with development, evaluation, implementation, and continual revisions of the current or future practice guidelines. o 1997 by the National Kidney Foundation, Inc.

T HE Dialysis Outcomes Quality Initiative (DOQI), sponsored by the National Kidney

Foundation (NKF), began in March 1995. Its main purpose is to systematically use the accrued

knowledge of dialysis and kidney disease to create practice guidelines and educational programs to benefit kidney patients. The final outcome objec- tives of the NKF-DOQI include the following:

improve patient survival, reduce patient morbid- ity, increase efficiency of care, and improve

quality of life for dialysis patients. In the initial attempt to achieve these objec-

tives, four work groups were established and an expert chairperson was appointed for each work group. Each work group chairperson then se- lected an interdisciplinary team to develop prac- tice guidelines in the four critical areas of hemodi-

alysis adequacy, peritoneal dialysis adequacy, vascular access, and anemia. Since then, a Nutri- tion Work Group has been established in addition

to the four original groups. The clinical areas for guideline development

Address reprirrt requesh to Linda McCann, RD, LD, Nutrition

Coordinator, Satellite Dialysis Cetrters, Irrc, Redwood City, (2.4

0 f997 by the National Kidney Fouttdation, Im.

1051.2276/97/0701-0007$03.00/O

Jotrmal qfRed Nutrition, Vol 7, No 1 (January), 1997: pp 39-42

were based on criteria from the Agency for

Health Care Policy and Research and included the following: significant benefits or risks associ-

ated with the practice in question, a high degree

of variability in practice, high levels of contro-

versy or uncertainty, significant numbers of pa-

tients affected by practice, availability of sufficient

information, and lack of contemporary practice

guidelines or strategies for implementation of

existing guidelines. An NKF-DOQI Advisory Council, which is

made up of nephrologists, nurses, administrators,

dietitians, social workers, and patients, convened

to provide multidisciplinary peer review and to facilitate implementation of the clinical guide-

lines. Further review was then requested from the

renal community.

The DOQI clinical practice guidelines are

based on information rigorously abstracted from

relevant scientific literature and supplemented by the clinical judgement of experts in the field who

participated on the work groups. Voluminous

scientific literature related to each topic was evaluated for relevance, and if relevant, subjected

to an intense abstraction process. Every study was reviewed for its methodological rigor. Papers

were judged accordingly and evidence-based tables were compiled to guide the expert discussion and

39

40 LINDA MCCANN

development of the guidelines. Where there was

unresolved controversy, differing positions were outlined and a consensus was not forced.

The DOQI guidelines reflect the current scien-

tific knowledge and expert opinion as it stands today. Each recommendation in the guidelines contains a rationale and discussion to enable

practitioners to evaluate information for them- selves and apply it to the specific needs of their patients. The clinical practice guidelines will be updated continually and enhanced as new knowl- edge emerges.

Many of the guidelines have potential implica- tions for renal dietitians. They strongly reinforce the importance of nutrition in the treatment of

renal failure and the value of the renal dietitian on the renal care team. They validate the work of

many dietitians who are already very involved with ensuring adequacy of dialysis and actively tracking the overall status of their patients. They

afford an opportunity for those dietitians who are minimally involved to expand their role and enhance their professional skills. The initial guide- lines propose standardization of adequacy measure- ments, serial assessment of nutritional status, and specific recommendations for iron nutriture. In

general, the DOQI guidelines offer the renal dietitian the following opportunities: enhance

skills and value, participate in patient and profes- sional education, implement programs to improve

patient outcomes and quality of life, participate in outcome measures that document cost-benefit of nutrition services, and increase job satisfaction, rewards, and recognition.

Hemodialysis Adequacy

The Hemodialysis Adequacy Guidelines

strongly support the use of formal urea kinetic modeling using a single pool, variable volume model (spw). This model was favored because it

allows an individual hemodialysis prescription to be developed, it provides a mechanism to check for errors in the delivered dose of hemodialysis, and it allows the computation of the protein catabolic rate. There is also a large body of research that shows the relationship between the spw dose of dialysis and patient survival. The complexity of the spw model is acknowledged as a minor limitation. Standardization of measure- ment techniques is proposed to allow the renal community to accrue and compare data, to iden-

tify successful strategies, and to improve patient outcomes.

The DOQI recommendations afford the renal dietitian an opportunity to lobby for formal urea kinetic modeling in those dialysis facilities that

have been relying upon other measures of ad- equacy that are potentially less accurate and do not provide the added nutritional parameter of

normalized protein catabolic rate. The guidelines validate what many renal dietitians already do and allow further recognition of their contributions to the provision of adequate dialysis and nutritional monitoring of renal patients.

Renal dietitians have the biochemical back- ground to analyze the kinetic modeling results and identify problems. They have the expertise to

help guide dialysis therapy and to play a major role in ensuring that their patients meet prescription

and delivery targets as recommended within the DOQI guidelines. Adequacy of dialysis param- eters can be added to the usual monthly laboratory parameters that the dietitian reviews with the patient. Dietitians also benefit from the added nutritional parameter of normalized protein cata- bolic rate to help them monitor nutritional status

and plan appropriate interventions. Those who have not developed the expertise to be integrally involved in formal urea kinetic modeling should

take this opportunity to educate themselves by carefully studying the guidelines, their evidence-

based rationale, and the problem-solving strate- gies. A small investment of time will allow them to enhance their professional value. Those dieti- tians who have very limited hours for patient care may have to use personal time to gain the knowledge and develop an expertise about formal urea kinetic modeling. But that knowledge and

expertise can promote positive patient outcomes and help establish cost-benefit data for nutrition care. Cost-benefit data can, in turn, help justify

improved staffing ratios with time to provide quality nutrition care. The DOQI guidelines for hemodialysis adequacy will provide an opportu- nity for a professional on the renal care team to play a pivotal role in implementing, tracking, and analyzing the measures of adequacy: why not the dietitian?

Anemia

The Anemia Workgroup very clearly outlines the importance of iron nutrition in the use of

NKF-DOQI: IMPLICATIONS FOR RENAL DIETITIANS 41

erythropoietin (EPO) to treat anemia in renal patients. Standardized methods of assessing ane- mia and iron stores are recommended. Targets for iron stores are suggested and methods of achiev- ing those targets are reviewed. Again, many dietitians are already very involved with ensuring that iron stores are high enough to maximize the effect of EPO. The DOQI evidence-based guide- lines validate the belief that prescribing EPO without ensuring adequate available iron is costly and wasteful. The guidelines suggest that most patients will require IV iron to maintain adequate iron stores. The renal dietitian can play a major role in tracking iron stores and helping the physician determine when IV iron may be needed. Patients who are unable to tolerate IV iron, will also benefit from the expertise of the renal dietitian who knows the best choice, dose, and timing of an oral iron supplement. Again, those dietitians who have limited time should afford themselves this opportunity to promote their value to the renal care team. The provision of adequate iron therapy can help renal dietitians document the cost and benefit of nutrition ser- vices and improve patient outcomes. Be proac- tive. Iron therapy is part of nutrition practice.

Peritoneal Dialysis Adequacy

Whereas most of the DOQI workgroups de- cided to defer to the Nutrition Workgroup on issues related to nutrition, the Peritoneal Dialysis (PD) Adequacy Workgroup felt that nutrition was so integrally involved with PD adequacy that it could not be deferred. The guidelines address many issues related to peritoneal dialysis such as when to initiate treatment, how to measure adequacy, adequacy targets, and suggested fre- quency of adequacy measures, standardized mea- surement techniques, indications and contraindi- cations for peritoneal dialysis, nutritional assessment, and outcome measurements. Each guideline is supported by evidence-based ratio- nale and/or expert opinion. This set of guidelines has a direct nutrition component in recommend- ing serial measurement of nutritional status using protein equivalent of total nitrogen appearance (PNA) and subjective global assessment (SGA).

Again, the importance of nutrition therapy and assessment in renal disease are underscored by inclusion of these recommendations in the PD adequacy guidelines. Renal dietitians have much

to gain by implementing these recommendations in their practice, if they have not already done so.

Research has shown that PNA or normalized PNA can indirectly estimate dietary protein in- take and provide a valuable measure of nutrition status in PD patients. This simple calculation can be performed and analyzed by the renal dietitian. The renal dietitian has the expertise to compare the PNA to recommended protein levels and to translate patient needs into meal plans and nutri- tion interventions. The evaluation of PNA may enable the dietitian to help identify inadequate treatment early in its course. Early identification and correction of inadequate treatment promises to positively impact nutritional status as well as overall patient outcomes. Again, the value of nutrition services may be shown through cost- benefit analysis and tracking of patient outcomes.

SGA is a technique that uses clinical expertise/ experience to evaluate the history and physical exam to assess and classify a patient’s nutritional status. The technique is simple and could be performed by a variety of professionals including the nurse, the physician, or the dietitian, although training and agreement on ratings should be in place to ensure consistency. The technique could be adequately performed by other professionals, but in-depth expertise on food/supplement com- position, gastrointestinal function, anthropom- etry, and actual compared with recommended dietary intake makes the renal dietitian the logical professional to perform this task most efficiently and effectively. The SGA formalizes much of what renal dietitians already do. It promotes the prioritization of patients based on their nutritional risk or need. The SGA can serve both as an initial screening tool and a tool for serial assessments. Again, this recommendation will be implemented by a professional on the renal care team. Should we defer to others to assess the nutritional status of our patients? Take the time and opportunity to develop the skills and expertise to implement these recommended nutritional assessment param- eters. They promise to provide another avenue for dietitians to assess the clinical and cost effective- ness of their interventions.

PD adequacy measures have been a part of the work load for many renal dietitians. Dietitian participation in the measurement of PD adequacy benefits the patient by combining the expertise of two professionals, the nurse and the dietitian. For renal dietitians who have not had the opportunity

42 LINDA MCCANN

to be integrally involved in PD kinetic modeling, the DOQI guidelines open a door for enhancing their skills and value.

Vascular Access

The Vascular Access work group guidelines address many issues including the prevention or

early recognition of access problems and promot- ing positive patient outcomes. The roles of the renal dietitian for issues of vascular access are not

as direct as with the other guideline topics. However, healthy vascular access is key to the adequacy of hemodialysis, and thus, could indi- rectly affect nutritional status. The renal dietitian who oversees formal urea kinetic modeling, may

also play a significant role in assessing and identify- ing access problems as he or she evaluates the delivered dose of dialysis, analyzes therapy errors,

tracks volume changes, and reviews documenta- tion of other treatment parameters. Also, nutri- tion is very important for the maintenance of

tissue integrity and wound healing, both of which can affect vascular access.

Nutrition

The Nutrition Work Group was established after the others and guidelines have not yet been released. It seems certain that the implications of

the nutrition guidelines will be forthright and will further validate the importance of the renal dieti-

tian on the renal care team. Renal dietitians can and should volunteer to be highly involved with the review process and implementation of guide- lines from this group. Watch for the opportunity!

Summary

The DOQI guidelines provide opportunities, as well as validation for renal dietitians. Each

clinical topic has nutrition implications that must be recognized and considered. Interventions, edu- cation tools, and outcome measures must be developed and implemented. The standardization that the DOQI guidelines propose will allow the renal community at large to accrue analogous data

that identify successful strategies for continuous quality improvement in the care of renal patients. Continuous quality improvement will, in turn,

promote positive outcomes that impact the pa- tient’s quality of life, the practice of renal profes-

sionals, and the financial aspects of the end-stage renal disease program.

The DOQI guidelines will be finalized after comment from the renal community at large. The

next step will be to implement the guidelines. Renal dietitians can and should play a very important role in the implementation, the evalua- tion, and the continual revision of the guidelines.