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  • Measure Summary
  • NQMC:000355
  • Oct 2002

Advanced chronic kidney disease (CKD): percent of patients with qualified nutritional counseling.

Renal Physicians Association. Appropriate patient preparation for renal replacement therapy. Rockville (MD): Renal Physicians Association; 2002 Oct 1. 78 p. (Clinical Practice Guideline; no. 3).

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in March 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure assesses the percent of patients with qualified nutritional counseling among patients with advanced chronic kidney disease (CKD) and evidence for malnutrition determined to be due to CKD.

Rationale

Nutritional interventions are commonly advised for patients with chronic kidney disease (CKD). A major goal of these interventions is to retard the progression of kidney disease and therefore delay the need for renal replacement therapy (RRT). To achieve this goal, the standard recommendation has been to restrict the intake of dietary protein, especially animal protein. This recommendation is based on animal studies that have shown that higher dietary intakes of protein can accelerate the progression of CKD, and in turn, restriction of dietary protein intake has been shown to slow progression of CKD. Another major goal of low-protein diets (LPDs) is to reduce the symptoms of uremia, metabolic acidosis and hyperphosphatemia that occur as CKD inevitably progresses.

Results from higher quality studies in humans with CKD are inconclusive regarding the beneficial effects of these diets on the progression of kidney disease; they also suggest that patients on lower protein diets may be at risk for malnutrition. For these reasons, the use of low-protein diets in CKD patients remains controversial.

Nutritional interventions have several other important goals. Regardless of prescribed diet, CKD patients are at risk for malnutrition, generally because of inadequate energy and protein intake resulting from decreased appetite. Therefore, many nutritional interventions recommend an increase in energy intake. Another goal is prevention of hyperphosphatemia; therefore it is often recommended that CKD patients restrict intake of organic and inorganic phosphates. Other nutritional interventions focus on the prevention of bone disease, vitamin and mineral deficiencies, and hyperlipidemia.

Two large, one medium-sized, and one small observational studies provide evidence to suggest that malnutrition in this population may be a function of decreased protein and energy intake. Most diet intervention studies in this population have emphasized energy intakes greater than 30 kcal/kg body weight/day. In addition, most studies evaluating a LPD did not limit protein intake much lower than 0.6 g/kg body weight/day. It was the opinion of the measure developer that patients with signs of malnutrition should have protein intakes at least this high.

Evidence for Rationale

Abdullah MS, Wild G, Jacob V, Milford-Ward A, Ryad R, Zanaty M, Ali MH, el Nahas AM. Cytokines and the malnutrition of chronic renal failure. Miner Electrolyte Metab. 1997;23(3-6):237-42. PubMed External Web Site Policy

Brenner BM. Hemodynamically mediated glomerular injury and the progressive nature of kidney disease. Kidney Int. 1983 Apr;23(4):647-55. PubMed External Web Site Policy

Klahr S, Buerkert J, Purkerson ML. Role of dietary factors in the progression of chronic renal disease. Kidney Int. 1983 Nov;24(5):579-87. [100 references] PubMed External Web Site Policy

Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, Striker G. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994 Mar 31;330(13):877-84. [64 references] PubMed External Web Site Policy

Kopple JD, Greene T, Chumlea WC, Hollinger D, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang SR, Zimmer GS. Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study. Kidney Int. 2000 Apr;57(4):1688-1703. PubMed External Web Site Policy

Renal Physicians Association. Appropriate patient preparation for renal replacement therapy. Rockville (MD): Renal Physicians Association; 2002 Oct 1. 78 p. (Clinical Practice Guideline; no. 3).

Walser M, Hill S. Can renal replacement be deferred by a supplemented very low protein diet?. J Am Soc Nephrol. 1999 Jan;10(1):110-6. PubMed External Web Site Policy

Woodrow G, Oldroyd B, Turney JH, Tompkins L, Brownjohn AM, Smith MA. Whole body and regional body composition in patients with chronic renal failure. Nephrol Dial Transplant. 1996 Aug;11(8):1613-8. PubMed External Web Site Policy

Primary Health Components

Advanced chronic kidney disease; malnutrition; diet assessment; nutritional counseling

Denominator Description

The number of adult patients with advanced chronic kidney disease (CKD), not currently receiving renal replacement therapy, and evidence for malnutrition determined to be due to CKD

Numerator Description

The number of patients from the denominator with qualified nutritional counseling

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)

Additional Information Supporting Need for the Measure

Three large and three small observational studies have demonstrated that patients with advanced chronic kidney disease (CKD) are at risk for malnutrition (decline in body weight, serum albumin, and other markers), and that this risk increases as glomerular filtration rate (GFR) declines. Furthermore, low serum albumin has been associated with increased mortality in end-stage renal disease (ESRD).

Evidence for Additional Information Supporting Need for the Measure

Abdullah MS, Wild G, Jacob V, Milford-Ward A, Ryad R, Zanaty M, Ali MH, el Nahas AM. Cytokines and the malnutrition of chronic renal failure. Miner Electrolyte Metab. 1997;23(3-6):237-42. PubMed External Web Site Policy

Gentile MG, Fellin G, Manna GM, D'Amico G. Effects of dietetic manipulation on the control of blood pressure and on the progression of chronic renal insufficiency. Scand J Urol Nephrol. 1988;108:13-5. PubMed External Web Site Policy

Greene T, Bourgoignie JJ, Habwe V, Kusek JW, Snetselaar LG, Soucie JM, Yamamoto ME. Baseline characteristics in the Modification of Diet in Renal Disease Study [corrected and republished article originally printed in J Am Soc Nephrol 1993 May;3(11):1819-34]. J Am Soc Nephrol. 1993 Nov;4(5):1221-36. [28 references] PubMed External Web Site Policy

Kopple JD, Greene T, Chumlea WC, Hollinger D, Maroni BJ, Merrill D, Scherch LK, Schulman G, Wang SR, Zimmer GS. Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study. Kidney Int. 2000 Apr;57(4):1688-1703. PubMed External Web Site Policy

Lowrie EG, Huang WH, Lew NL. Death risk predictors among peritoneal dialysis and hemodialysis patients: a preliminary comparison. Am J Kidney Dis. 1995 Jul;26(1):220-8. PubMed External Web Site Policy

Woodrow G, Oldroyd B, Turney JH, Tompkins L, Brownjohn AM, Smith MA. Whole body and regional body composition in patients with chronic renal failure. Nephrol Dial Transplant. 1996 Aug;11(8):1613-8. PubMed External Web Site Policy

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Person- and Family-centered Care
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Patient-centeredness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Adult patients age 18 years and older with chronic kidney disease (CKD) stage 4 or 5 (glomerular filtration rate [GFR] less than or equal to 30 mL/min/1.73 m2), not currently receiving renal replacement therapy, with evidence for malnutrition* determined to be due to CKD

*Evidence of malnutrition due to CKD:

  • An unintentional decline in body weight by more than 5%,
  • Decrease in serum albumin by more than 0.3 g/dL or is less than 4.0 g/dL (for Bromo-Cresol-Green assay or 3.7 for Bromo-Cresol-Purple assay), and
  • All other causes of malnutrition are ruled out

Note: Other markers of nutritional status could also be used.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
The number of patients from the denominator with qualified nutritional counseling*

*Qualified nutritional counseling is diet assessment and counseling by qualified personnel.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Laboratory data

Paper medical record

Patient/Individual survey

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Number of patients with qualified nutritional counseling / number of patients with advanced CKD and evidence for malnutrition determined to be due to CKD.

Measure Collection Name

Clinical Performance Measures on Appropriate Patient Preparation for Renal Replacement Therapy

Measure Set Name

Nutrition Recommendations

Submitter

Renal Physicians Association - Medical Specialty Society

Developer

Renal Physicians Association - Medical Specialty Society

Funding Source(s)

Ortho Biotech Products, LP

Composition of the Group that Developed the Measure

W. Kline Bolton, MD, Working Group Chair, University of Virginia School of Medicine, Charlottesville, VA; William F. Owen, Jr., MD, President, RPA, Duke University School of Medicine Durham, NC; Baxter Healthcare Corp., McGaw Park, IL; Dale Singer, MHA, Executive Director, RPA.

Content Experts: Jack Coburn, MD, UCLA School of Medicine, West Los Angeles V.A. Healthcare Center, West Los Angeles, CA; William Haley, MD, Mayo Clinic, Jacksonville, FL; Annamaria Kausz, MD, New England Medical Center, Boston, MA; Adeera Levin, MD, St. Paul's Hospital, Vancouver, BC; William Mitch, MD, University of Texas Medical Branch, Galveston, TX; Patricia Painter, PhD, University of California, San Francisco, CA; Michael Rocco, MD, MSCE, Wake Forest University School of Medicine, Winston-Salem, NC.

Association Representatives: Carolyn Atkins, RN, BS, CCTC, National Kidney Foundation, Medical City Dallas Hospital, Dallas, TX; Shelley Clark, RN, National Renal Administrators Association, FMC North Roanoke Dialysis, Roanoke, VA; Paul Eggers, PhD, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD; Lori Fedje, RD, LD, NKF Council on Renal Nutrition, Pacific Northwest Renal Services, Portland, OR; Richard Goldman, MD, Renal Physicians Association, Renal Medicine Associates, Emeritus Albuquerque, NM; Joel Greer, PhD, Centers for Medicare and Medicaid Services, Baltimore, MD; Richard Lafayette, MD, American Society of Nephrology, Stanford University School of Medicine, Stanford, CA; Eugene Z. Oddone, MD, American College of Physicians - American Society of Internal Medicine, Durham VA Medical Center, Durham, NC; Victoria Norwood, MD, American Society of Pediatric Nephrology, University of Virginia, Charlottesville, VA; Paul M. Palevsky, MD, Forum of ESRD Networks, University of Pittsburgh School of Medicine, VA Pittsburgh Health Care System, Pittsburgh, PA; Sandy Peckens, MSW, NKF Council of Nephrology Social Workers, Merrimack Valley Nephrology, Methuen, MA; Venkateswara Rao, MD, American Society of Transplantation, Hennepin County Medical Center, Minneapolis, MN; Charlotte Thomas Hawkins, PhD, RN, CNN, American Nephrology Nurses Association, Rutgers, The State University of New Jersey, Burlington, NJ; Joseph White, American Association of Kidney Patients.

Methodologists: David B. Matchar, MD, FACP, Director, Duke Center for Clinical Health Policy Research and Co-Director, Duke Evidence-based Practice Center, Durham, NC; Douglas C. McCrory, MD, MHS, Co-Director Duke Evidence-based Practice Center, Durham, NC; Joseph A. Coladonato, MD, Duke Institute of Renal Outcomes Research & Health Policy, Durham, NC; Preston S. Klassen, MD, MHS, Duke Institute of Renal Outcomes Research & Health Policy, Durham, NC; Meenal B. Patwardhan, MD, MHSA, Duke Center for Clinical Health Policy Research and Duke Evidence-based Practice Center, Durham, NC; Donal N. Reddan, MD, MHS, Duke Institute of Renal Outcomes Research & Health Policy, Durham, NC; Olivier T. Rutschmann, MD, MPH, Duke Center for Clinical Health Policy Research, Durham, NC; William S. Yancy, Jr., MD, MHS, Duke University Medical Center, Durham, NC.

Medical Editor: Rebecca N. Gray, DPhil, Duke Evidence-based Practice Center, Durham, NC.

Project Manager and Editor: Emily G. Shurr, MA, Duke Evidence-based Practice Center, Durham, NC.

Financial Disclosures/Other Potential Conflicts of Interest

There were none disclosed.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2002 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in March 2016.

Source(s)

Renal Physicians Association. Appropriate patient preparation for renal replacement therapy. Rockville (MD): Renal Physicians Association; 2002 Oct 1. 78 p. (Clinical Practice Guideline; no. 3).

Measure Availability

Source not available electronically.

For more information, contact the Renal Physicians Association (RPA) at 1700 Rockville Pike, Suite 220, Rockville, MD 20852; Phone: 301-468-3515; Fax: 301-468-3511; Web site: www.renalmd.org External Web Site Policy; E-mail: rpa@renalmd.org.

NQMC Status

This NQMC summary was completed by ECRI on May 23, 2003. The information was verified by the Renal Physicians Association on June 17, 2003.

This NQMC summary was retrofitted into the new template on May 6, 2011.

The information was reaffirmed by the measure developer on March 11, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

For more information, contact RPA at 1700 Rockville Pike, Suite 220, Rockville, MD 20852; phone: 301-468-3515; fax: 301-468-3511; Web site: www.renalmd.org External Web Site Policy; e-mail: rpa@renalmd.org.

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