The Role of Nutrition in the Patient With CKD
In this video, James Matera, DO, speaks with nephrologist Wayne Kotzker, MD, primary care physician Maria Ciminelli, MD, cardiologist Lance Berger, MD, and nutritionist Jamie Miller, RD, about the role of nutrition in a patient with chronic kidney disease (CKD), including the importance of dietary modification in patients with CKD and proteinuria or albuminuria, the role of potassium in patients with advanced CKD, how to set realistic dietary goals for patients with CKD, and more.
- Diabetes food hub. American Diabetes Association. Accessed March 13, 2023. https://www.diabetesfoodhub.org/
- Eatright.org. Academy of Nutrition and Dietetics. Accessed March 13, 2023. https://www.eatright.org/
- National Kidney Foundation. Accessed March 13, 2023. https://www.kidney.org/
For more chronic kidney disease content, visit the Resource Center.
James Matera, DO, is a practicing nephrologist, Senior Vice President for Medical Affairs, and Chief Medical Officer at CentraState Medical Center (Freehold, NJ).
Maria Ciminelli, MD, is a primary care physician, Chair of the Family Medicine Residency Program at CentraState Medical Center, and Vice Chair of the Rutgers Family Medicine Residency Program (Freehold, NJ).
Lance Berger, MD, is a cardiologist at Monmouth Cardologiy Associates LLC and Medical Director of the Echocardiography Laboratory at Jersey Shore University Medical Center (Neptune, NJ).
Jamie Miller, RD, is a dietitian and diabetes care and education specialist in the Renal and Pancreas Transplant Division at Saint Barnabas Medical Center and an adjunct professor in the Nutrition and Food Studies Department at Montclair State University (Livingston, NJ).
Wayne Kotzker, MD, is a nephrologist at Florida Kidney Physicians and an associate professor of medicine at Nova Southeastern University School of Medicine and Charles E. Schmidt Medical School at Florida Atlantic University (Boca Raton, FL).
Good evening and thank you for joining our roundtable today on our discussion of a multidisciplinary approach to the evaluation and management of patients with chronic kidney disease. I'm pleased to have put together a roundtable of some experts in the field. I'd like to introduce Dr. Maria Ciminelli. She is the chair of our family medicine residency program at Centra State and also the Vice Chairman of the Rutgers Family Medicine Residency Program. Dr Lance Berger is a cardiologist. He's an FACC and he's also the medical director of the echocardiography lab at Jersey Shore Medical Center and recently has an extra credential in cardio-oncology. Dr Berger is with Monmouth Cardiology. We have Ms Jamie Miller, who's a registered dietician and particularly in the diabetes and transplant clinic from Saint Barnabas Medical Center in Livingston, and Dr Wayne Kotzker, who is the clinical leader of value-based care from Florida Kidney Physicians, and he has a number of academic appointments as well.
I do want to spend a brief time talking about, specifically, dietary issues when it comes to CKD. Because again, we kind of mentioned in the first part of the webinar that it's often very difficult to get our patients to align to an appropriate diet. In particular, as they get further advanced in chronic kidney disease, Wayne, I want to talk a little bit about potassium. We all know that we want to maximize our ACEs and our ARBs. Over the last couple of years, we've had the benefit of having potassium-binding resins that we can use in order to extend the patient's life on using the ACEs and ARBs, but a lot of people don't want to take a medicine to counteract what's going on with another medicine. What are some of the things you do when you're faced with a patient in stage three or stage four who has pretty significant hyperkalemia?
You're right. We are very fortunate that we live in an era where we have a better potassium-lowering medication than sodium polystyrene, which certainly is not something that patients could take long term. There is that, but I think before we get to that, you're correct. We have medications that we know that help to slow the progression of kidney disease, and modify their risk factors, ACEs, ARBs, MRAs, and yet some of these medications are very much antagonistic to potassium management. They raise potassium. We know that as we drop the glomerular-filtration rate, that'll also have an effect on potassium. What I usually do is I don't just tell patients you cannot take something and reduce their diet and say no potassium. I think Jamie mentioned earlier that nothing is a no-go. You have to manage patients and what their preferences are. We have one of these guides that has low, medium, and high potassium foods so that they can see that if I'm saying you need to limit potassium, well there are alternatives on the lower side that you can substitute for the higher. Again, I would certainly refer to a dietician to help manage.
A lot of times it isn't just what their dietary intake is, because as we said, the medications that they're on, the worsening kidney function, that is going to cause some potassium retention and increase potassium regardless of how well they try to manage it with their diet. At that point, I will usually have a discussion with a patient about why am I using a medication that is causing their potassium to go up. If I feel strongly that the ACE or ARB is slowing their progression, is giving them benefits, is reducing their proteinuria, then I will talk to them about going on those potassium binders, Lokelma, Veltassa, those medications that are easier to take long term. I'll often explain, you're taking this medication to get the benefit of the other medication, and yes, you're taking now two medications, but the benefit of the one really justifies you taking another medication because it is difficult to manage the potassium just through diet alone.
Totally agree. Totally agree. Jamie, all these foods that we try to keep them away from with potassium, they're all good. I like potassium-containing foods. How do we deal on your side with someone who's chronic hyperkalemia and how do we try to keep them on the right track?
Yeah. That's a really good point. Honestly, a lot of my patients do get very frustrated and confused because a lot of times, as you said, the foods that are high in potassium are good. They're considered extremely healthy, and we often promote them when we're talking about general healthy eating, such as avocados and dark leafy greens like spinach and kale, bananas, oranges, and potatoes. These are all very nutrient-dense foods that are definitely a very important part of a generally healthy diet. However, when we introduce kidney disease and hyperkalemia, it becomes a bit of an issue, but with the higher, moderate, and low potassium fruits and vegetables that were mentioned, I also have a guide that has nice little pictures of the fruits and vegetables on each side. It's higher potassium fruits, lower potassium fruits, and the same with vegetables. I like to go through it with them and see what we can replace the higher potassium items with.
There are a ton of low-potassium fruits and vegetables that we can certainly swap in to make sure that they're getting enough fiber and they're getting their other micronutrients, but just not too much potassium. Swapping in red peppers instead of tomatoes in a recipe or pureeing it up and making a soup that way or things like that. Substituting some of the fruits like grapes and apples and pears that are lower in potassium for some of those higher items like oranges or bananas that somebody may have. Really just little modifications. Usually, we can find a happy medium, things that patients do enjoy eating and they can still enjoy those healthy foods, but just not those very high potassium ones that tend to make it more difficult to keep that potassium within normal limits or where we want it.
Good. Dr Berger, we know that our patients have cardiovascular risk factors. We know that we want to keep their LDL down as low sometimes, you said, 55, and we know that statins are often not the greatest medications. People don't like to take them for whatever reason, even though they have such great benefits. How do you deal with a patient with chronic kidney disease to get them bought in to keep in their lipid panel as best as possible?
That's a great question and it's something that we face daily. As you said, the concern about statin therapy, patients have side effects, and many times before they take the medication and it becomes a real challenge. How do you handle that? When it comes to statin therapy, I've been enamored by a recent study, where they called an N of one study in patients who received pill bottles with either statin or placebo, they were given an app and they were told to mark down their muscle symptoms and they didn't know one month after the other which they were taking, whether a placebo, whether a statin. It turned out that half of the patients enrolled in this trial who were already having statin-associated muscle symptoms, they already had SAMS, and just as much SAMS with the placebo as they did with statin therapy. We now call this a nocebo effect.
When I explain to patients the benefits of statin therapy and I sit with them and I draw them what the plaque looks like, and I discuss the concept of a vulnerable versus invulnerable plaque and I take the time to go through it, you see the light bulb go off and they're much more likely to take the treatment, and especially the CKD patients who as we've mentioned are very high risk for cardiovascular events. It really does take time to be able to explain to people what it is you're trying to accomplish. That is plaque neutralization, plaque stabilization, and hopefully converting these vulnerable plaques in the hypertensive, diabetic, CKD patient with high inflammatory milieu to a much more stable plaque at lower risk of rupture and lower risk of causing events.
Yeah, no doubt. I think, again, that just underlines the whole idea of the multidisciplinary approach. Maria, your diabetic, hypertensive, chronic kidney disease patient sees all of our docs and they know about their lipids, they know about their potassium, they know about their low protein diet, and they come to you and complain and say, all these doctors are making me eat cardboard. What do we do? How do you handle that situation knowing how important it is in the management?
It's an everyday event. You're absolutely correct. Patients will come in and certainly say, how am I supposed to balance all this? This one's worried about my cholesterol and this one's worried about my potassium, and how do I make it all fit? It's very confusing. It can be very, very complex for patients to understand. For me, it just gets back down to the education, but then also incorporating and engaging support systems for the patient, whether it be their family member who does the cooking, somebody else who can help them in terms of exercise, but it's very important to get others involved in their care; just like we say, the multidisciplinary approach in regards to handling what we request of them in terms of what are the best medications, the lifestyle changes in terms of all the physicians and other parts of our healthcare team. Like the dietician and the diabetes educators for our diabetics, it's just as important to incorporate their support system in their families.
I often find that I am supporting or, again, reinforcing the same kind of information that my colleague nephrologists and cardiologists are in terms of the importance of medication adherence and dietary adherence and exercise, all of these factors, smoking cessation, etc., in terms of reducing their risk of death and mortality from cardiovascular disease, which is the most common thing that's going to kill our patients with CKD. Then also discussing with them how we reverse or decrease the progression of chronic kidney disease by staying true to the medications, diet, exercise, and just a healthy lifestyle in general.
Yeah, absolutely. I think not only that, but the morbidity, mortality, and the costs of the care, everything particularly in our diabetic subpopulation that's going to have all these other social things. Actually, I just thought of something here. We'll have to get this group together again. What I'd love to do is have everybody put together a playbook, if you will, for managing the chronic kidney disease patient. I just thought of another webinar for the future, but let's close out with some take-home points. Let's start with Wayne. Any take-home points regarding dietary modification in kidney disease?
Well, I think the big things or the big things that I usually tell patients, following a low sodium diet's important, the low potassium in those patients who do have some issues with potassium regulation, often advocating a more plant-based protein substitution for animal protein, trying to stay away from red meat and what we think that definitely exacerbates or accelerates CKD. Then those patients who can manage volume, if they can drink around 64 ounces per day, obviously earlier on, those who don't have low ejection fraction or heart failure who can manage and can stay up with their fluids, that also does help in terms of diluting the potassium, diluting the sodium in their diet, delivering more volume to the kidneys and allowing for that clearance to improve. I think when you balance it, that's generally the approach that I look at for my patients.
Good. Jamie, any take-home points or any resources that you know of that you give to your patients?
Yeah, definitely. The resources, that's a really important thing. We can educate patients while they're in the clinic or even over the phone or answer any questions that they may have, but when it comes to having something printed out for them or something available for them to reference when they're home and their significant other or their family member or caregiver is trying to figure out what they can and can't eat, or maybe thinking of new recipes to try. There are certainly a lot of different really great resources, especially online. Of course, we always want to make sure that they're evidence-based because the internet can be a little scary when it comes to patients looking for information on how to manage kidney disease and diabetes and all of that.
One I usually recommend would be the National Kidney Foundation, kidney.org. They have a lot of good nutrition stuff on there. Very simple and it kind of explains to the patient why they need to limit these different nutrients and the effect that the higher levels may have on their body and really just breaking it down simply for them. When it comes to diabetes and kidney disease, the American Diabetes Association has an excellent resource more recently called Diabetes Food Hub. They actually have really great tips on there for managing diabetes. There is even a component that mentions kidney disease and helps with that. They have excellent recipes. Nothing boring. I always tell my patients it's nothing boring or bland. They're really good recipes. They have different cultures and all of that too, which I love. You can search by meal, by dietary preference. If you have any things that you avoid or a certain diet that you're following, you can select that and narrow things down, so I really like to recommend that, especially if somebody is looking for actual recipes or meals.
Then the Academy of Nutrition and Dietetics, eatright.org, they have a lot of good resources as well. Also, the dialysis units. Some of them do have really great nutrition information on there, even for patients who are not on dialysis. They have a lot of really good resources for pre-modality patients. I usually do recommend those things too for my transplant patients that are getting evaluated for transplant that are pre-dialysis, when we're talking about preserving their renal function and hopefully avoiding dialysis before they get the transplant. I always recommend going on those websites because it's very comprehensive, but yet again, really break things down simply. The bottom line is basically making sure that it is evidence-based, but also I do provide them with a list of things that I would recommend for them to check out.
That's a great point. I have patients come in all the time telling me something they saw on the internet to drink, some type of juice or something like that. Evidence-based is key.
Dr Berger, how about some take-home points on our cardiovascular side for our patients?
Sure. Thank you for that. I think the biggest take-home message would be the importance of collaboration, the critical nature of dietary management, and oftentimes what I would consider a reasonable diet as a cardiologist could cross purposes of the kidney patient, and engaging a dietician is helpful. The other part of the collaboration I think is really essential is to have our other providers, nephrologists, and primary care doctors in the loop as well. If somebody's seeing a nephrologist, I want to make sure that my progress notes are going there. I have most of the nephrologists that I work with on, as I call it, speed dial, and have no concern picking up a phone and calling and saying, "hey, I want to talk to you about this case." The collaboration that we've mentioned on a couple of occasions today is really essential for better outcomes. Having a dietician involved and having us all speaking together reduces cross purposes that we're sometimes acting towards each other. I think that's critical.
I don't want to say antagonistic, but sometimes against each other. Just the other day, we had a conversation last Friday about a patient who was in the room with me and we got on the same page, and as usual, you and I were on the same wavelength, which is always nice. Okay, Maria, last but not least, what are some good take-home points that you want to see or mention about the care of CKD patients when it comes to diet?
I think everybody has really captured it in regard to the importance of collaboration and a multidisciplinary approach. From the primary care perspective, as a family physician, it's so important for me to get that communication. We talked about that in another segment, so that I can reinforce what my nephrologist, cardiologist, and dietician are telling my patients, because after seeing a patient for 20 years, when they hear it from me again, reemphasizing what the cardiologist and nephrologist have told them, I think really helps because of the trust and the relationship that we have with our patients when we're seeing them for so long.
In terms of some of the frustrations, patients will tell me, "yeah, I saw the dietician. Yes, I've gotten these recipes, but it's really hard to do this." And just to be empathic with our patients and to really listen to them. That's a component that I think is important from the primary care perspective is to be empathetic, to listen, to try to help them in terms of reinforcing the tools that people like Jamie and the dieticians will give our patients all. I'll often suggest experimenting with natural herbs and spices. Forget the salt, forget any of those salt substitutes that will increase your potassium, but use natural herbs and spices and play with it and have fun with it in order to invigorate your food. Sometimes that really helps them.
I think the patients hearing that from you in particular, but from the whole group, reinforces to them that A, we care about them, and B, we understand and we know what we can do to try to reduce the risk modification. Well, this has been a great discussion. We can go on for days talking about things like this, but I love the collegial nature. I certainly thank you. I consider you all colleagues and we will continue to do some good work together. Once again, thank you all for joining us, and I hope everybody has a great evening.
Thank you for having us.