Initiation of Very Low Energy Diets in Adults with severe ...



Canberra Hospital and Health ServicesClinical ProcedureInitiation of Very Low Energy Diets in Adults with severe Chronic Kidney DiseaseContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc492372672 \h 1Purpose PAGEREF _Toc492372673 \h 2Scope PAGEREF _Toc492372674 \h 2Section 1 – Initiation process for Very Low Energy Diet PAGEREF _Toc492372675 \h 2Section 2 – Risks of very low energy diets in severe chronic kidney disease and unit with primary responsibility for managing those risks. PAGEREF _Toc492372676 \h 3Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc492372677 \h 3References PAGEREF _Toc492372678 \h 4Definition of Terms PAGEREF _Toc492372679 \h 5Search Terms PAGEREF _Toc492372680 \h 6PurposeThe purpose of this procedure is to provide safe management of rapid weight loss from very low energy diets (VLED) when these are utilised in adults with severe chronic kidney disease (CKD). It sets out what is considered a reasonable minimum renal and obesity service follow-up interval to manage anticipated complications of rapid weight loss. For the purposes of this document severe chronic kidney disease is defined as any adult with an estimated glomerular filtration rate less than 30 mL/min/1.73m2. Back to Table of ContentsScopeThis procedure applies to the following staff working within their scope of practice:Medical Officers Nurses DieticiansStudents under direct supervision.This procedure is targeted at patients of ACT Health Renal Service Network with stage 2 or 3 obesity that are being considered for a VLED by the ACT Health Obesity Management Service.Back to Table of ContentsSection 1 – Initiation process for Very Low Energy DietPatient assessed by Obesity Management Service as suitable for a VLED. Patient provided by Obesity Management Service with information detailing the potential risks and benefits of a VLED. Patients choosing to proceed with a VLED should be discussed with their usual renal physician by the Obesity Management Service.Dialysis patients proceeding with a VLED are to be referred by their nephrologist to the clinic manager at the Belconnen Health Centre Dialysis Clinic (the haemodialysis unit) and non-dialysis patients are to be referred to the Chronic Kidney Diseases Coordinator.Renal service to arrange a weekly dialysis session (for patients already receiving haemodialysis) at the Belconnen Dialysis Clinic to commence when the VLED is initiated.Renal Service to arrange weekly appointments with a nephrologist at the Belconnen Health Centre for dialysis patients, or fortnightly appointments at the Belconnen Health Centre for non-dialysis patients. These appointments are to be scheduled to commence on initiation of the VLED and to continue at this frequency for the duration of a VLED that is resulting in an estimated 2kg non-fluid weight loss/week or greater. If the patient’s usual nephrologist is unable to provide this frequency of review then, with the usual nephrologist’s permission, the Obesity Management Service may refer to a nephrologist that is able to provide this service.The patient commences a VLED as per normal Obesity Management Service Protocols. Back to Table of Contents Section 2 – Risks of very low energy diets in severe chronic kidney disease and unit with primary responsibility for managing those risks.Table 1: Risks and risk reduction strategies when VLED is used in moderate to severe chronic kidney disease (eGFR ≤45mL/min/1.73m2 by CKD-EPI equation)RiskPreventative StrategySpeciality ResponsibleActionHypotension*Weekly BP monitoring and fortnightly physical examination, extended to monthly after 4 weeks if clinically appropriate.RenalAdjustment of antihypertensives, euvolaemic weight target and diuretics as required.Hypertension**Weekly assessment of haemodialysis record and assessment of volume status if haemodialysis record indicates a significant alteration in BPRenalAdjustment of antihypertensives, euvolaemic weight target and diuretics as required.Hyperuricosuria*Spot urine pH at baseline and weekly for 2 weeks preferably by urine dipstick performed at point of careRenalAdjustment of alkalai therapy as required.Electrolyte Disturbance and acute kidney injuryWeekly EUC Urate and CPM extended to monthly after 4 weeks if clinically appropriateRenalIncrease electrolytes that are too low, decrease electrolytes that are too high as clinically appropriate.Hypo or hyperglycaemiaAs per usual Obesity Service PracticeObesityIncrease or decrease hypoglycaemic medication as clinically appropriate.* Applies only to non-dialysis CKD**Applies only to haemodialysis patientsBack to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentActive Management of Larger (Bariatric) Adult Patients PolicyProceduresHealthcare Associated Infections Clinical ProcedurePatient Identification and Procedure Matching PolicyGuidelines Fasting Guidelines – Elective and Emergency SurgeryLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferences ADDIN ZOTERO_BIBL {"custom":[]} CSL_BIBLIOGRAPHY 1.Nestle Health Science, Optifast? VLCDTM Clinical Treatment Protocol. Available at: . (Accessed: 17th May 2017)2.Mann, J. F. et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. The Lancet 372, 547–553 (2008).3.Klahr, S. et al. The Effects of Dietary Protein Restriction and Blood-Pressure Control on the Progression of Chronic Renal Disease. N. Engl. J. Med. 330, 877–884 (1994).4.Malvy, D., Maingourd, C., Pengloan, J., Bagros, P. & Nivet, H. Effects of severe protein restriction with ketoanalogues in advanced renal failure. J. Am. Coll. Nutr. 18, 481–486 (1999).5.Sigler, M. H. The mechanism of the natriuresis of fasting. J. Clin. Invest. 55, 377–387 (1975).6.Colles, S. L., Dixon, J. B., Marks, P., Strauss, B. J. & O’Brien, P. E. Preoperative weight loss with a very-low-energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am. J. Clin. Nutr. 84, 304–311 (2006).7.Tsai, A. G. & Wadden, T. A. The Evolution of Very-Low-Calorie Diets: An Update and Meta-analysis. Obesity 14, 1283–1293 (2006).8.Amatruda, J. M., Richeson, J. F., Welle, S. L., Brodows, R. G. & Lockwood, D. H. The Safety and Efficacy of a Controlled Low-Energy (’Very-Low-Calorie’) Diet in the Treatment of Non-Insulin-Dependent Diabetes and Obesity. Arch. Intern. Med. 148, 873–877 (1988).9.Henry, R. R., Wiest-Kent, T. A., Scheaffer, L., Kolterman, O. G. & Olefsky, J. M. Metabolic consequences of very-low-calorie diet therapy in obese non-insulin-dependent diabetic and nondiabetic subjects. Diabetes 35, 155–164 (1986).10.Friedman, A. N., Chambers, M., Kamendulis, L. M. & Temmerman, J. Short-Term Changes after a Weight Reduction Intervention in Advanced Diabetic Nephropathy. Clin. J. Am. Soc. Nephrol. 8, 1892–1898 (2013).11.Lassemillante, A.-C. M., Oliver, V., Hickman, I., Murray, E. & Campbell, K. L. Meal replacements as a strategy for weight loss in obese hemodialysis patients. Hemodial. Int. 20, E18–E23 (2016).12.Levey, A. S. et al. A new equation to estimate glomerular filtration rate. Ann. Intern. Med. 150, 604–12 (2009).Back to Table of ContentsDefinition of TermsSevere chronic kidney diseaseEstimated GFR below 30 mL/min/1.73sqm body surface area as determined by the CKD-EPI equation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a13smi5oop7","properties":{"formattedCitation":"{\\rtf \\super 12\\nosupersub{}}","plainCitation":"12"},"citationItems":[{"id":943,"uris":[""],"uri":[""],"itemData":{"id":943,"type":"article-journal","title":"A new equation to estimate glomerular filtration rate","container-title":"Annals of Internal Medicine","page":"604-12","volume":"150","issue":"9","source":"NLM","archive_location":"19414839","abstract":"BACKGROUND: Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. OBJECTIVE: To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. DESIGN: Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. SETTING: Research studies and clinical populations (\"studies\") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. PARTICIPANTS: 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. MEASUREMENTS: GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. RESULTS: In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). LIMITATION: The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. CONCLUSION: The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. PRIMARY FUNDING SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases.","ISSN":"1539-3704 (Electronic) 0003-4819 (Linking)","shortTitle":"A new equation to estimate glomerular filtration rate","language":"eng","author":[{"family":"Levey","given":"A. S."},{"family":"Stevens","given":"L. A."},{"family":"Schmid","given":"C. H."},{"family":"Zhang","given":"Y. L."},{"family":"Castro","given":"A. F.","suffix":"3rd"},{"family":"Feldman","given":"H. I."},{"family":"Kusek","given":"J. W."},{"family":"Eggers","given":"P."},{"family":"Van Lente","given":"F."},{"family":"Greene","given":"T."},{"family":"Coresh","given":"J."}],"issued":{"date-parts":[["2009",5,5]]}}}],"schema":""} 12.HypotensionThis is a blood pressure that is considered too low. What is considered too low depends on clinical judgement.HypertensionThis is a blood pressure over 140mmHg systolic or over 90mmHg diastolic. Elimination of hypertension is not always a treatment target.HyperuricosuriaThis is an excess (compared to the pathology laboratory reference range) daily excretion of uric acid and urate.Electrolyte disturbanceThis is when an electrolyte in plasma or serum is either above, or below, the pathology laboratory reference range. Commonly measured electrolytes are magnesium, calcium, phosphorus, sodium, potassium, bicarbonate, urate, and chloride.Acute Kidney InjuryThis is where the kidney suffers acute loss of function as defined for the purposes of this document as a rise in serum or plasma creatinine of more than 26 micromol/LHypoglycaemiaThis is a blood sugar that is too low. What is considered too low for an individual patient depends on specific patient characteristics, however a plasma glucose <2.5 mmol/L is always too low.HyperglycaemiaThis is a blood sugar that is too high. What is considered too high depends on the post-prandial period and other patient characteristics such as age, com-morbidities and frailty. A blood sugar >11 mmol/L is always abnormal.Back to Table of ContentsSearch Terms Diet, Chronic kidney disease, Very low energy, Very low calorie, kidney, haemodialysis, VLED, dialysis, CKD, obesity, management, Back to Table of ContentsDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC Chair ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download