CLINICAL PRACTICE GUIDELINE FOR NUTRITION IN 
                                                                           CHRONIC KIDNEY DISEASE: 2019 UPDATE 
                                    
                                    
                                    
                                    
                                    
                                    
                                    
                                    
                                    
                                    
                                    
                                    
                                                                                                                          Public Review DRAFT  
                                                                                                                                         October 2019 
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                                    Guideline on Nutrition in CKD 
                                   SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE 
                                    
                                      This Clinical Practice Guideline document is based upon the best information available as of 
                                      April 2017*. It is designed to provide information and assist decision making. It is not intended 
                                      to define a standard of care, and should not be construed as one, nor should it be interpreted as 
                                      prescribing  an  exclusive  course  of  management.  Variations  in  practice  will  inevitably  and 
                                      appropriately occur when clinicians take into account the needs of individual patients, available 
                                      resources,  and  limitations  unique  to  an  institution  or  type  of  practice.  Every  health-care 
                                      professional  making  use  of  these  recommendations  is  responsible  for  evaluating  the 
                                      appropriateness  of  applying  them  in  the  setting  of  any  particular  clinical  situation.  The 
                                      recommendations for research contained within this document are general and do not imply a 
                                      specific protocol. 
                                    
                                      *Commissioned evidence review included articles published through April 2017. Consensus 
                                      opinion statements use literature published though August 2018. 
                                    
                                    
                                    
                                   SECTION II: DISCLOSURE 
                                    
                                      Kidney Disease Outcomes Quality Initiative (KDOQI) and American Academy of Nutrition and 
                                      Dietetics (AND) make every effort to avoid any actual or reasonably perceived conflicts of 
                                      interest  that  may  arise as  a  result  of  an  outside  relationship  or  a  personal,  professional,  or 
                                      business interest of a member of the Work Group. All members of the Work Group are required to 
                                      complete, sign, and submit a disclosure and attestation form showing all such relationships that 
                                      might be perceived or actual conflicts of interest. All reported information will be printed 
                                      in the final publication and are on file at the National Kidney Foundation (NKF). 
                                    
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                                    Guideline on Nutrition in CKD 
                                                                                                                       TABLE OF CONTENTS 
                      
                            Table of Tables……………………………………………………………………………………….…….  4 
                            Table of Figures………………………………………………………………………………………….…  4 
                            Abbreviations and Acronyms………………………………………………………………………………  5 
                            Work Group Membership………………………………………………………………………………….  8 
                            Organization Leadership……………………………………………………………..…………………….  9 
                            Abstract…………………………………………………………………………………………………….  NA 
                            Foreword……………………………………………………………………………………………………  NA 
                            Methods…….................................................................................................................................................                                                                                             10 
                            Summary of Guideline Statements...............................................................................................................                                                                                                         25 
                            Guideline 1: Assessment……………………………………………………………..……………...……  36 
                                   1.0 Usual Care Statements                                                                                                                                                                                                                       36 
                                   ………………………………………………………………………………… 
                                   1.1 Technical Devices & Anthropometric Measurements to Measure Body Composition ……………                                                                                                                                                           36 
                                   1.2 Laboratory Measures of Body Composition ……………………………………………………….  50 
                                   1.3 Handgrip Strength ………………………………………………………………………………….  57 
                                   1.4 Methods to Assess Energy Requirements ………………………………………………………….  59 
                                   1.5 Composite Nutritional Indices to Measure Nutritional Status in CKD Patients …………………...                                                                                                                                                      62 
                                   1.6 Tools/Methods Used to Assess Protein Intake and Calorie Intake ………………….……………...  71 
                            Guideline 2: Medical Nutrition Therapy……………………………………………...…………………  74 
                            Guideline 3: Dietary Protein and Energy Intake……………………….……………………………….  82 
                                   3.0 Energy Intake ……………………………………………………………………………………….  82 
                                   3.1 Protein Amount  ………….………………………………………………………………………...  82 
                                   3.2 Protein Type ……………………………………………………………………………………….  94 
                                   3.3 Dietary patterns (Fruits and Vegetables; Mediterranean) …………….…………………………….  98 
                            Guideline 4: Nutritional Supplementation ………………………………………..……………………                                                                                                                                                                                     103 
                                   4.1 Nutrition Supplementation - Oral, Enteral, and Parental Nutrition ………………………                                                                                                                                                                 103 
                                   ……………………………….. 
                                   4.2 Nutrition Supplementation - Dialysate………………………………………..…….……                                                                                                                                                                                 115 
                                   4.3 Long Chain Omega-3 Polyunsaturated Fatty Acids ....…………………………..............                                                                                                                                                                 119 
                            Guideline 5: Micronutrients.……………………………………………………….………….                                                                                                                                                                                                128 
                                   5.0 General Guidance ………………………………………………………………………..                                                                                                                                                                                              128 
                                   5.1 Folic acid (with and without other B Vitamins) ……..……………………………………..............                                                                                                                                                             132 
                                   5.2 Vitamin C …………………………………………………………………………………..............  137 
                                   5.3 Vitamin D …………………………………………………………………………………..............  142 
                                   5.4 Vitamin E and A ……………………………………………..……………………………..............  148 
                                   5.5 Vitamin K …………………………………………………………………………………..............  155 
                                   5.6 Selenium and Zinc…………………………………………………………………………………..  159 
                            Guideline 6: Electrolytes.………………………………………………………………………….…….                                                                                                                                                                                             164 
                                   6.1 Acid-Base …………………………………………………………………………………..............  164 
                                   6.2 Calcium ………………………………………………………………..……………………............  171 
                                   6.3 Phosphorus …………………………………………………………...……………………..............  175 
                                   6.4 Potassium ……………………………………………………………….…………………..............  184 
                                   6.5 Sodium …………………………………………………………….………………………..............  188 
                            Biographic and Disclosure Information………………………………………………………………….                                                                                                                                                                                        196 
                            References………………………………………………………………………………………………….  206 
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                     Guideline on Nutrition in CKD 
                                TABLES 
                                    Table 1. Key Questions for Evidence Review ………………………………………………….   16 
                                    Table 2. Evidence Review Inclusion and Exclusion Criteria …………………………………...  18 
                                    Table 3. Quality of Evidence Grades ……………………………………………………………  24 
                                    Table 4. Implications of strong and weak recommendations for different users of guidelines …. 25 
                                 
                                 
                                 
                                 
                                FIGURES 
                                    Figure 1. Flow diagram of identified studies for Assessment questions ………………..……….. 21 
                                    Figure 2. Flow diagram of identified studies for Intervention questions ……………….…..…… 22
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                                 Guideline on Nutrition in CKD