Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease

Cristina Martins Simone L. Saeki Marcelo Mazza do Nascimento Fernando M. Lucas Júnior Ana Maria Vavruk Christiane L. Meireles Sandra Justino Denise Mafra Estela Iraci Rabito Maria Eliana Madalozzo Schieferdecker Letícia Fuganti Campos Denise P. J. van Aanholt Ana Adélia Hordonho Marcia Samia Pinheiro Fidelix About the authors

Abstract

This nutrition consensus document is the first to coordinate the efforts of three professional organizations - the Brazilian Association of Nutrition (Asbran), the Brazilian Society of Nephrology (SBN), and the Brazilian Society of Parenteral and Enteral Nutrition (Braspen/SBNPE) - to select terminology and international standardized tools used in nutrition care. Its purpose is to improve the training delivered to nutritionists working with adult patients with chronic kidney disease (CKD). Eleven questions were developed concerning patient screening, care, and nutrition outcome management. The recommendations set out in this document were developed based on international guidelines and papers published in electronic databases such as PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane. From a list of internationally standardized terms, twenty nutritionists selected the ones they deemed relevant in clinical practice involving outpatients with CKD. The content validity index (CVI) was calculated with 80% agreement in the answers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess the strength of evidence and recommendations. A total of 107 terms related to Nutrition Assessment and Reassessment, 28 to Diagnosis, nine to Intervention, and 94 to Monitoring and Evaluation were selected. The list of selected terms and identified tools will be used in the development of training programs and the implementation of standardized nutrition terminology for nutritionists working with patients with chronic kidney disease in Brazil.

Keywords:
Nutritional Sciences; Malnutrition; Renal Insufficiency, Chronic; Food Assistance; Terminology

Resumo

Este consenso representa a primeira colaboração entre três organizações profissionais com foco em nutrição: Associação Brasileira de Nutrição (Asbran), Sociedade Brasileira de Nefrologia (SBN) e Sociedade Brasileira de Nutrição Parenteral e Enteral (Braspen/SBNPE), com o objetivo de identificar a terminologia e instrumentos padronizados internacionalmente para o processo de cuidado em nutrição. O foco é facilitar a condução de treinamentos de nutricionistas que trabalham com pacientes adultos com doenças renais crônicas (DRC). Foram levantadas onze questões relacionadas à triagem, ao processo de cuidado e à gestão de resultados em nutrição. As recomendações foram baseadas em diretrizes internacionais e em bancos de dados eletrônicos, como PubMed, EMBASE(tm), CINHAL, Web of Science e Cochrane. A partir do envio de listas de termos padronizados internacionalmente, vinte nutricionistas especialistas selecionaram aqueles que consideraram muito claros e relevantes para a prática clínica com pacientes ambulatoriais com DRC. Foi calculado o Índice de Validade de Conteúdo (IVC), com 80% de concordância nas respostas. O Grading of Recommendations, Assessment, Development and Evaluation (GRADE) foi usado para atribuir força de evidência às recomendações. Foram selecionados 107 termos de Avaliação e Reavaliação, 28 de Diagnóstico, 9 de Intervenção e 94 de Monitoramento e Aferição em Nutrição. A lista de termos selecionados e identificação de instrumentos auxiliará no planejamento de treinamentos e na implementação de terminologia padronizada em nutrição no Brasil, para nutricionistas que trabalham com pacientes renais crônicos.

Descritores:
Ciências da Nutrição; Desnutrição; Insuficiência Renal Crônica; Assistência Alimentar; Terminologia

Introduction

Nutritional status plays a fundamental role in the health and clinical outcomes of individuals with chronic kidney disease (CKD). Malnutrition is a highly prevalent condition closely linked to adverse clinical outcomes and increased hospitalization, complication, and death rates in this population11 Piccoli GB, Lippi F, Fois A, Gendrot L, Nielsen L, Vigreux J, et al. Intradialytic nutrition and hemodialysis prescriptions: a personalized stepwise approach. Nutrients. 2020 Mar;12(3):785.,22 Koppe L, Fouque D, Kalantar-Zadeh K. Kidney cachexia or protein-energy wasting in chronic kidney disease: facts and numbers. J Cachexia Sarcopenia Muscle. 2019 Jun;10(3):479-84.. The pathogenesis of malnutrition in CKD is multifactorial and complex, and its main causes revolve around reduced food intake, nutrient anabolism, and hypercatabolism11 Piccoli GB, Lippi F, Fois A, Gendrot L, Nielsen L, Vigreux J, et al. Intradialytic nutrition and hemodialysis prescriptions: a personalized stepwise approach. Nutrients. 2020 Mar;12(3):785.

2 Koppe L, Fouque D, Kalantar-Zadeh K. Kidney cachexia or protein-energy wasting in chronic kidney disease: facts and numbers. J Cachexia Sarcopenia Muscle. 2019 Jun;10(3):479-84.
-33 Oliveira EA, Zheng R, Carter CE, Mak RH. Cachexia/protein energy wasting syndrome in CKD: causation and treatment. Semin Dial. 2019 Nov;32(6):493-9..

The use of standardized terminology and tools is required to clearly document the impact of nutrition care and capture the specificity of prescribed care measures. Standardization enhances search capabilities in electronic databases and communication of medical facts in electronic patient charts. Examples of standardization in nephrology include the KDIGO (Kidney Disease Improving Global Outcomes) and the KDOQI (Kidney Disease Outcomes Quality Initiative). A recent publication on nomenclature for kidney disease attempted to improve communication between health care workers and the population44 Levey AS, Eckardt K, Dorman NM, Christiansen SL, Hoorn EJ, Ingelfinger JR, et al. Nomenclature for kidney function and disease report of a Kidney Disease: Improving Global Outcomes (KDIGO) consensus conference. Kidney Int. 2020 Jun;97(6):1117-29..

Using predetermined terms and accurate data enables the comprehension of the links connecting problems, specific interventions, and significant outcomes reached in nutrition and health. Standardized terminology and tools provide for a consistent means to capture care actions and describe positive outcomes from nutritional and health care interventions.

The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) of the World Health Organization is the official system used to designate diagnostic and medical procedure codes. Although some concepts from nutrition have been incorporated in the ICD-10, they are insufficient when it comes to characterizing nutritional problems and specific interventions prescribed by nutritionists. The work of nurses and physicians encompasses different areas, and the needs of both are different from the needs of other health care workers.

Some international nomenclature systems used in electronic patient charts offer some potential to include nutrition terminology. One of them is the SNOMED-CT (Systematized Nomenclature of Medicine-Clinical Terms) (http://www.snomed.org/), maintained by the International Health Terminology Standards Development Organization (IHTSDO) since 2007. The system was initially developed to encompass diseases, but eventually progressed considerably to include terms from other areas of knowledge, such as nursing and nutrition. The SNOMED-CT is considered the most complete and accurate terminology database. Brazil joined SNOMED International in 2018. Therefore, the standardization of clinical terminology - including nutrition care - has become a matter of national interest.

In Nephrology, patients often move between outpatient and inpatient care. Therefore, the standardization of nutrition terms and tools, particularly considering the use of electronic charts and records, optimizes the sharing of data and the communication between institutions, improves data quality and intervention outcomes, increases patient safety by allowing seamless care, decreases rework, and saves time and money. However, nutrition terminology has not been standardized in Brazil and electronic patient charts have not been developed to allow the entry of structured data (without free text). These relevant processes are challenging, and require good planning and strong solutions.

The purpose of this consensus document was to identify selected terms in nutrition from international nomenclature to improve the training of nutritionists working with patients with kidney disease in Brazil. It also aimed to find validated screening and malnutrition diagnostic tools that might be incorporated in the practice of this group of nutritionists. Therefore, the target audience of this consensus document is nutritionists working with adult individuals (age > 18 years) with CKD in outpatient care with non-dialysis dependent kidney disease, on hemodialysis (HD), on peritoneal dialysis (PD), and kidney transplant patients.

Questions

Eleven questions covering three topics were defined, as described below. The 2019 edition of the Nutrition Care Process Terminology (NCPT) translated into Portuguese after validation by two reviewers, both nutritionists who have Portuguese as their mother tongue, in line with the criteria set out by the Academy of Nutrition and Dietetics (Academy), was used as a reference.

    Topic: Screening and referral systems for patients with CKD
  1. Which malnutrition screening tool should be used?

    Topic: Nutrition care process for patients with CKD
  1. 2. Should the nutrition care process (NCP) and the Nutrition Care Process Terminology (NCPT) be standardized?

  2. 3. Which Nutrition Assessment and Reassessment standardized terms are deemed very relevant by Brazilian nutritionists?

  3. 4. Which Nutrition Diagnosis standardized terms are deemed very relevant by specialist nutritionists?

  4. 5. Should malnutrition be defined based on etiology?

  5. 6. Which malnutrition diagnostic tool should be used?

  6. 7. Which Nutrition Intervention standardized terms are deemed very relevant by specialist nutritionists?

  7. 8. Which reference standards for daily nutrient and food intake are recommended?

  8. 9. Which Nutrition Monitoring and Evaluation standardized terms are deemed very relevant by specialist nutritionists?

    Topic: Outcome management system for patients with CKD
  1. 10. Which format should be used in the documentation of NCP data?

  2. 11. Which indicators should be used in nutrition outcome management?

Experienced nutritionists (with at least two years of practice with outpatients with CKD) were selected to answer the questions on the selection of terms. Specialist nutritionists were emailed the list of terms of the NCPT and were asked to individually select terms they deemed very relevant in CKD outpatient clinical practice. The answers were collected in a spreadsheet containing all NCPT codes.

The content validity index (CVI) was calculated to determine and quantify content validity55 Grant JS, Davis LL. Selection and use of content experts for instrument development. Res Nurs Health. 1997 Jun;20(3):269-74.,66 Davis LL. Instrument review: getting the most from a panel of experts. Appl Nurs Res. 1992 Nov;5(4):194-7.. The CVI comprises a scale from 1 to 4, in which 1 - not relevant; 2 - somewhat relevant; 3 - quite relevant; 4 - highly relevant. On account of the great number of standardized terms, specialist nutritionists were asked to pick only the terms rated as "4" in the CVI scale (number of answers rated as "4" / total number of answers).

Since more than six specialists answered the questionnaire, an agreement rate of 80% was stipulated as the threshold to characterize answers representing the group's opinions77 Polit DF, Beck CT. The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health. 2006 Oct;29(5):489-97.,88 Lynn MR. Determination and quantification of content validity. Nurs Res. 1986 Nov/Dec;35(6):382-5..

Levels of evidence

The recommendations made in this document were derived and adapted from consensus documents and international guidelines cited in the References section. Whenever questions could not be answered with the aid of international guidelines or consensus documents, searches were made (by August 31, 2020) in electronic databases - PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane - for relevant papers. Evidence cited in guidelines, consensus documents, and literature were discussed and listed in a table of levels of evidence, with recommendations produced subsequently. Agreement within the working group was used as a reference in cases in which evidence was inconclusive or insufficient.

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE)99 Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr;336(7650):924-6. framework was used to assess the strength of evidence (Chart 1). The GRADE framework has been extensively used and is deemed a methodologically sound, easy-to-use tool.

Chart 1
Grading of Recommendations, Assessment, Development and Evaluation (GRADE)99 Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr;336(7650):924-6. Framework

Strength of recommendation (Chart 2) was assessed based on discussions including expert opinions, cost-effectiveness of the recommendations, costs and reviewed supporting evidence, followed by the use of the Delphi method and voting, until agreement was reached.

Chart 2
Strength of recommendation

Recommendations For The Screening And Referral System

Comments

The MST supports the NCP. Screening helps to identify patients at risk of malnutrition and may be performed in any clinical practice environment. In addition to nutritionists, trained individuals (physicians, nurses, nutrition technicians, interns, family members, patients, etc.) may conduct screening sessions1010 Skipper A, Coltman A, Tomesko J, Charney P, Porcari J, Piemonte TA, et al. Position of the Academy of Nutrition and Dietetics: malnutrition (undernutrition) screening tools for all adults. J Acad Nutr Diet. 2020 Apr;120(4):709-13.,1111 Field LB, Hand RK. Differentiating malnutrition screening and assessment: a nutrition care process perspective. J Acad Nutr Diet. 2015 May;115(5):824-8.. Screening may be useful for patients assessed, diagnosed, and treated by a nutritionist. Screened patients may be prescribed nutrition care.

Numerous screening tools have been developed and/or validated for patients with CKD. They include the Geriatric Nutritional Risk Index (GNRI), validated for patients on HD1212 Komatsu M, Okazaki M, Tsuchiya K, Kawaguchi H, Nitta K. Geriatric nutritional risk index is a simple predictor of mortality in chronic hemodialysis patients. Blood Purif. 2015;39(4):281-7. and PD1313 Kang SH, Cho KH, Park JW, Yoon KW, Do JY. Geriatric nutritional risk index as a prognostic factor in peritoneal dialysis patients. Perit Dial Int. 2013 Jul/Aug;33(4):405-10.; the Nutritional Risk Screening 2002 (NRS-2002) validated for patients on HD1414 Führ LM, Wazlawik E, Garcia MF. The predictive value of composite methods of nutritional assessment on mortality among haemodialysis patients. Clin Nutr ESPEN. 2015 Feb;10(1):e21-e5.; and the Renal Nutrition Screening Tool (R-NST), validated for hospitalized individuals with kidney disease1515 Xia YA, Healy A, Kruger R. Developing and validating a renal nutrition screening tool to effectively identify undernutrition risk among renal inpatients. J Ren Nutr. 2016 Sep;26(5):299-307..

Ideally, a tool should function regardless of underlying disease, age, or site of application to acknowledge risk of malnutrition. In other words, it should not address specific patient populations, but allow for universal use instead. Therefore, this consensus supports the systematic review published by Skipper et al1616 Skipper A, Coltman A, Tomesko J, Charney P, Porcari J, Piemonte TA, et al. Adult malnutrition (undernutrition) screening: an evidence analysis center systematic review. J Acad Nutr Diet. 2019 Apr;120(4):669-708. DOI: https://doi.org/10.1016/j.jand.2019.09.010
https://doi.org/10.1016/j.jand.2019.09.0...
. and the more recent position of the Academy1010 Skipper A, Coltman A, Tomesko J, Charney P, Porcari J, Piemonte TA, et al. Position of the Academy of Nutrition and Dietetics: malnutrition (undernutrition) screening tools for all adults. J Acad Nutr Diet. 2020 Apr;120(4):709-13., which have described the MST (Chart 3) as the tool with the best validity, agreement, and reliability, regardless of age, medical history, or site where the patient is offered care. The MST has been validated and shown good generalization for patients with acute disease, on long-term treatment, rehabilitation, outpatients, and individuals treated for cancer in at least nine different countries1717 Abbott J, Teleni L, McKavanagh D, Watson J, McCarthy A, Isenring E. A novel, automated nutrition screening system as a predictor of nutritional risk in an oncology day treatment unit (ODTU). Support Care Cancer. 2014 Aug;22(8):2107-12.

18 Arribas L, Hurtós L, Sendrós MJ, Peiró I, Salleras N, Fort E, et al. NUTRISCORE: a new nutritional screening tool for oncological outpatients. Nutrition. 2017 Jan;33:297-303.

19 Bell JJ, Bauer JD, Capra S. The malnutrition screening tool versus objective measures to detect malnutrition in hip fracture. J Hum Nutr Diet. 2013 Dec;26(6):519-26.

20 Ferguson ML, Bauer J, Gallagher B, Capra S, Christie DR, Mason BR. Validation of a malnutrition screening tool for patients receiving radiotherapy. Australas Radiol. 1999 Aug;43(3):325-7.

21 Gabrielson DK, Scaffidi D, Leung E, Stoyanoff L, Robinson J, Nisebaum R, et al. Use of an abridged scored patient-generated subjective global assessment (abPG-SGA) as a nutritional screening tool for cancer patients in an outpatient setting. Nutr Cancer. 2013;65(2):234-9.

22 Isenring E, Cross G, Daniels L, Kellett E, Koczwara B. Validity of the malnutrition screening tool as an effective predictor of nutritional risk in oncology outpatients receiving chemotherapy. Support Care Cancer. 2006 Nov;14(11):1152-6.

23 Isenring EA, Bauer JD, Banks M, Gaskill D. The malnutrition screening tool is a useful tool for identifying malnutrition risk in residential aged care. J Hum Nutr Diet. 2009 Dec;22(6):545-50.

24 Isenring EA, Banks M, Ferguson M, Bauer JD. Beyond malnutrition screening: appropriate methods to guide nutrition care for aged care residents. J Acad Nutr Diet. 2012 Mar;112(3):376-81.

25 Lawson CS, Campbell KL, Dimakopoulos I, Dockrell MEC. Assessing the validity and reliability of the MUST and MST nutrition screening tools in renal inpatients. J Ren Nutr. 2012 Sep;22(5):499-506.

26 Azian MZN, Suzana S, Romzi M. Sensitivity, specificity, predictive value and inter-rater reliability of malnutrition screening tools in hospitalised adult patients. Malays J Nutr. 2014;20(2):209-19.

27 Nursal TZ, Noyan T, Atalay BG, Köz N, Karakayali H. Simple two-part tool for screening of malnutrition. Nutrition. 2005 Jun;21(6):659-65.

28 Shaw C, Fleuret C, Pickard JM, Mohammed K, Black G, Wedlake L. Comparison of a novel, simple nutrition screening tool for adult oncology inpatients and the Malnutrition Screening Tool (MST) against the Patient-Generated Subjective Global Assessment (PG-SGA). Support Care Cancer. 2015 Jan;23(1):47-54.

29 Ulltang M, Vivanti AP, Murray E. Malnutrition prevalence in a medical assessment and planning unit and its association with hospital readmission. Aust Health Rev. 2013 Nov;37(5):636-41.

30 Wu ML, Courtney MD, Shortridge-Baggett LM, Finlayson K, Isenring EA. Validity of the malnutrition screening tool for older adults at high risk of hospital readmission. J Gerontol Nurs. 2012 Jun;38(6):38-45.

31 Young AM, Kidston S, Banks MD, Mudge AM, Isenring EA. Malnutrition screening tools: comparison against two validated nutrition assessment methods in older medical inpatients. Nutrition. 2013 Jan;29(1):101-6.

32 Vicente MA, Barao K, Silva TD, Forones NM. What are the most effective methods for assessment of nutritional status in outpatients with gastric and colorectal cancer?. Nutr Hosp. 2013 May/Jun;28(3):585-91.

33 Hogan D, Lan LT, Diep DTN, Gallegos D, Collins PF. Nutritional status of Vietnamese outpatients with chronic obstructive pulmonary disease. J Hum Nutr Diet. 2017 Feb;30(1):83-9.

34 Marshall S, Young A, Bauer J, Isenring E. Nutrition screening in geriatric rehabilitation: criterion (concurrent and predictive) validity of the malnutrition screening tool and the mini nutritional assessment-short form. J Acad Nutr Diet. 2016 May;116(5):795-801.
-3535 Neelemaat F, Meijers J, Kruizenga H, Van Ballegooijen H, Van Der Schueren MVB. Comparison of five malnutrition screening tools in one hospital inpatient sample. J Clin Nurs. 2011 Aug;20(15-16):2144-52..

Chart 3
Malnutrition Screening Tool - MST

The KDOQI does not indicate a specific tool to screen patients for risk of malnutrition, although it states screening for malnutrition should be performed at least twice a year for patients with CKD stages 3-5, individuals on dialysis, and patients in post-kidney transplant care3636 Ikizler TA, Burrowes J, Byham-Gray L, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020 Sep;76(3 Suppl 1):S1-S107..

The simplicity of the MST allows the tool to be put to use by patients themselves, their family members and caretakers, in addition to health care workers. A study revealed that the MST is a reliable, valid tool that accurately identifies risk of malnutrition when used by individuals with cancer in outpatient care compared to a situation in which nutritionists use the tool to identify patients at risk3737 Di Bela A, Croisier E, Blake C, Pelecanos A, Bauer J, Brown T. Assessing the concurrent validity and interrater reliability of patient-led screening using the malnutrition screening tool in the ambulatory cancer care outpatient setting. J Acad Nutr Diet. 2020 Jul;120(7):1210-5..

Since malnutrition is a significant risk for patients with CKD strongly related to morbidity and mortality, we recommend that screening be performed at least once a month. Patients can self-administer the screening tool or have their caretakers involved. This consensus group also suggests that campaigns should be organized to build the awareness of patients and health care workers over the need to administer the MST frequently.

Recommendations for the nutrition care process

Comments

The nutrition care process (NCP) adopted by the Academy3939 Academy of Nutrition and Dietetics (AND). International collaboration and translations. Nutrition terminology reference manual (eNCPT): dietetics language for nutrition care [Internet]. Chicago: AND; 2005; [access in 2020 Mar 20]. Available from: http://www.ncpro.org/international-collaboration
http://www.ncpro.org/international-colla...
is a systematic, complete, thorough approach to collect, verify, categorize, interpret, and document data. It comprises four steps, each organized based on categories, classes, and subclasses4040 Swan WI, Pertel D, Hotson B, Lloyd L, Orrevall Y, Torstler N, et al. Nutrition care process (NCP) update part 2: developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes. J Acad Nutr Diet. 2019 May;119(5):840-55.. The steps are Nutrition Assessment and Reassessment; Diagnosis; Intervention; and Monitoring and Evaluation. Nutritionists are required to go through the four steps of the NCP. Each step must be completed before moving on to the next.

Nutrition Care Process Terminology (NCPT) is the professional language used to standardize and encode specific terms4040 Swan WI, Pertel D, Hotson B, Lloyd L, Orrevall Y, Torstler N, et al. Nutrition care process (NCP) update part 2: developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes. J Acad Nutr Diet. 2019 May;119(5):840-55.. It is the controlled glossary that supplements the NCP. The NCPT is a system hierarchically organized (Figure 1) to produce accurate, specific descriptions of the services delivered by nutritionists. The NCPT aims to improve the quality of care and related outcomes4040 Swan WI, Pertel D, Hotson B, Lloyd L, Orrevall Y, Torstler N, et al. Nutrition care process (NCP) update part 2: developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes. J Acad Nutr Diet. 2019 May;119(5):840-55..

Figure 1
Standardized categories of the four steps of the Nutrition Care Process version 2019,40 with the number of terms for each step.

Use of the NCPT has been reported in instructional practices and environments4141 Hakel-Smith N, Lewis NM, Eskridge KM. Orientation to nutrition care process standards improves nutrition care documentation by nutrition practitioners. J Am Diet Assoc. 2005 Oct;105(10):1582-9.

42 Lövestam E, Boström AM, Orrevall Y. Nutrition care process implementation: experiences in various dietetics environments in Sweden. J Acad Nutr Diet. 2017 Nov;117(11):1738-48.

43 Lövestam E, Orrevall Y, Koochek A, Anderson A. The struggle to balance system and lifeworld: Swedish dietitians' experiences of a standardised nutrition care process and terminology. Health Sociol Rev. 2016;25(3):240-55.

44 Myers EF, Trostler N, Varsha V, Voet H. Insights from the diabetes in india nutrition guidelines study: adopting innovations using a knowledge transfer model. Top Clin Nutr. 2017 Jan;32(1):69-86.

45 Rossi M, Campbell KL, Ferguson M. Implementation of the nutrition care process and international dietetics and nutrition terminology in a single-center hemodialysis unit: comparing paper vs electronic records. J Acad Nutr Diet. 2014 Jan;114(1):124-30.

46 Thompson KL, Davidson P, Swan WI, Hand RK, Rising C, Dunn AV, et al. Nutrition care process chains: the "missing link" between research and evidence-based practice. J Acad Nutr Diet. 2015 Sep;115(9):1491-8.
-4747 Tilakavati K, Reinhard T, Shanthi K, Shy-Pyng T, Chee-Hee S. Incorporating the nutrition care process model into dietetics internship evaluation: a Malaysian university experience. Nutr Diet. 2016 Mar;73(3):283-95. in different parts of the world4848 Enrione EB, Reed D, Myers EF. Limited agreement on etiologies and signs/symptoms among registered dietitian nutritionists in clinical practice. J Am Diet Assoc. 2016;116(7):1178-86.,4949 Carpenter A, Mann J, Yanchis D, Campbell A, Bannister L, Vresk L. Implementing a clinical practice change: adopting the nutrition care process. Can J Diet Pract Res. 2019 Mar;80(3):127-30.. Implementation has been linked to numerous improvements. The NCPT helps to develop a common framework for routine care and research in nutrition. Standardized terminology may also encourage critical thinking and more focused and productive data documentation, potentially improving communication between health care workers.

The Academy, alongside other international organizations, has made significant efforts to establish the NCPT as a global language. Terms are updated once a year and made available on a web platform. The NCPT has also been adjusted to meet the requirements of international health systems and evidence-based guidelines4646 Thompson KL, Davidson P, Swan WI, Hand RK, Rising C, Dunn AV, et al. Nutrition care process chains: the "missing link" between research and evidence-based practice. J Acad Nutr Diet. 2015 Sep;115(9):1491-8.,5050 Hand RK, Murphy WJ, Field LB, Lee JA, Parrott JS, Ferguson M, et al. Validation of the Academy/A.S.P.E.N. malnutrition clinical characteristics. J Acad Nutr Diet. 2016 May;116(5):856-64.

51 Murphy WJ, Yadrick MM, Steiber AL, Mohan V, Papoutsakis C. Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII): a pilot study on the documentation of the nutrition care process and the usability of ANDHII by registered dietitian nutritionists. J Acad Nutr Diet. 2018 Oct;118(10):1966-74.
-5252 Papoutsakis C, Moloney L, Sinley RC, Acosta A, Handu D, Steiber AL. Academy of nutrition and dietetics methodology for developing evidence-based nutrition practice guidelines. J Acad Nutr Diet. 2017 May;117(5):794-804.. Since 2011, the terms of the NCP steps have been included in interdisciplinary international standards such as the SNOMED-CT5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14.. They reflect the standardized clinical terminology used in electronic patient chart systems used in several countries. Although they have been translated into several languages and dialects, a study showed that the NCP and the NCPT have not been fully adopted in the clinical practice of nutritionists working with patients with CKD, mostly due to lack of information5454 Dent LA, McDuffie I. A survey of the utilization of the nutrition care process for documentation in outpatient dialysis centers. Meeting Abstracts. J Ren Nutr. 2011;(1):205-7..

In 2014, the ASBRAN took the first steps toward international standardization and published the Guidelines for Systematization of Nutrition Care (Manual Orientativo: Sistematização do Cuidado em Nutrição - SICNUT)5555 Associação Brasileira de Nutrição (ASBRAN); Fidelix MSP. Manual orientativo: sistematização do cuidado de nutrição. São Paulo: ASBRAN; 2014.. The SICNUT contains the diagnostic nutrition recommendations proposed by the Academy. The ASBRAN entered into a partnership with the Academy in 2015, and has a seat in the International NCPT Subcommittee. In 2016-2018, the NCP and NCPT manuals were translated into Portuguese and validated as per the criteria set out by the Academy. In 2020, the Brazilian Consortium for Research and Implementation of the NCPT was created, with the Federal University of Paraná (UFPR) as the first Reference Center for research and training on the NCPT in the nation. The development of consensus documents within specialties in nutrition is one of the elements in the strategic plan developed by the Consortium.

The standardization of the NCPT in Brazil will also help to implement the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII®), a web-based data acquisition platform.53 The ANDHII® is based on the NCPT, and can be easily integrated into other healthcare information systems at a relatively low cost. It has been used in education, research, medical practices, and public health centers in the United States and various other countries5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14.. Using one single information system will undoubtedly lead to significant savings of time and resources in dialysis clinics, hospitals, outpatient clinics, medical practices, and other healthcare services. It may also encourage additional local and global research in nutrition and health.

Comments

Assessment and Reassessment involves a systematic approach to collecting, categorizing, and summarizing nutritional data. The goal is to describe the nutritional status and the problems related to nutrition and their etiology4040 Swan WI, Pertel D, Hotson B, Lloyd L, Orrevall Y, Torstler N, et al. Nutrition care process (NCP) update part 2: developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes. J Acad Nutr Diet. 2019 May;119(5):840-55.. Findings are compared to criteria or standards, reference frameworks (national, international or regulatory), or health care provider and patient-defined goals. Collected data may also be used to manage the quality of nutrition care.

Etiology guides the intervention plan designed to improve patient nutrition status. The search for etiology is an important element in Nutrition Assessment and Reassessment, since it is particularly useful in connecting diagnosis and intervention5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14.. The NCPT standardizes and encodes etiology, thus allowing the identification of the types of intervention that might address specific problems. Each diagnosis in nutrition may stem from different etiologies.

The NCPT encompasses a large number of terms that support the work of nutritionists in every area in which their presence is needed, including neonatology, public health, sports, and medical practices. Since it has not been widely used in a number of areas, including nephrology, starting from a shorter list of terms may facilitate professional training and the implementation of the NCPT. Table 1 presents a selection of terms in Assessment and Reassessment deemed essential by nutritionists specialized in working with patients with CKD.

Table 1
Nutrition Assessment and Reassessment Terms deemed essential by nutritionists specialized in kidney disease

Comments

Nutrition diagnosis states a specific problem that may be resolved or improved by means of intervention by a nutritionist.

The adoption of diagnostic language is a central element in documentation, since it standardizes the terminology used to name patient health problems and needs5656 Hakel-Smith N, Lewis NM. A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes. J Am Diet Assoc. 2004 Dec;104(12):1878-84.. Studies are currently in progress to validate the contents of the section on diagnosis in the NCPT. An early study has tested the content for validity5757 Enrione EB. Content validation of nutrition diagnoses. Top Clin Nutr. 2008;23(4):306-19.. Validation has also been performed by nutritionists specialized in pediatrics5858 Soares L, Auslander MH, Enrione EB. Application of the international dietetics and nutrition terminology for nutrition diagnosis among board certified specialists in pediatric nutrition. J Acad Nutr Diet. 2015;115(9 Suppl 1):A22., gerontology5959 Ritter-Gooder PK, Lewis NM, Eskridge KM. Content validation of a standardized language diagnosis by certified specialists in gerontological nutrition. J Am Diet Assoc. 2011 Apr;111(4):561-6., and oncology6060 Enrione EB, Villar J. Content validation of two nutrition diagnosis commonly identified in oncology patients. J Acad Nutr Diet. 2013;113:A13.. Although additional refinement is needed, the terminology has been considered acceptable. Table 2 presents the terms selected by expert nutritionists.

Table 2
Nutrition Diagnosis Terms deemed essential by nutritionists specialized in chronic kidney disease

Comments

In nephrology, there is a vast number of terms for malnutrition, including uremic malnutrition6161 Klaric D, Žepina M, Klaric V. Malnutrition in patients on dialysis treatment. Acta Med Croatica. 2016;70(Suppl 2):55-8., kidney cachexia/uremic cachexia6262 Ruperto M, Sánchez-Muniz FJ, Barril G. A clinical approach to the nutritional care process in protein-energy wasting hemodialysis patients. Nutr Hosp. 2014 Apr;29(4):735-50., sarcopenia in kidney disease6363 Tangvoraphonkchai K, Hung R, Sadeghi-Alavijeh O, Davenport A. Differences in prevalence of muscle weakness (sarcopenia) in haemodialysis patients determined by hand grip strength due to variation in guideline definitions of sarcopenia. Nutr Clin Pract. 2018 Apr;33(2):255-60.,6464 Hirai K, Ookawara S, Morishita Y. Sarcopenia and physical inactivity in patients with chronic kidney disease. Nephrourol Mon. 2016 May;8(3):e37443., malnutrition, inflammation, and atherosclerosis (MIA) syndrome6565 Bergström J, Lindholm B. Malnutrition, cardiac disease, and mortality: an integrated point of view. Am J Kidney Dis. 1998 Nov;32(5):834-41.

66 Efendic E, Lindholm B, Bergström J, Stenvinkel P. Strong connection between malnutrition, inflammation and arteriosclerosis. Improved treatment of renal failure if underlying factors are attacked. Lakartidningen. 1999 Oct;96(42):4538-42.

67 Stenvinkel P, Heimburger O, Paultre F, Diczfalusy U, Wang T, Berglund L, et al. Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney Int. 1999 May;55(5):1899-911.
-6868 Pertosa G, Simone S, Soccio M, Marrone D, Grandaliano G. Chronic inflammation and cardiovascular risk in hemodialysis. G Ital Nefrol. 2003 Nov/Dec;20(6):631-40. or malnutrition-inflammation complex syndrome (MICS), protein-energy malnutrition6969 Alvarenga LA, Andrade BD, Moreira MA, Nascimento RP, Macedo ID, Aguiar AS. Nutritional profile of hemodialysis patients concerning treatment time. J Bras Nefrol. 2017;39(3):283-6. and protein-energy wasting7070 Pérez-Torres A, Garcia MEG, Valiente BSJ, Rubio MAB, Diez OC, López-Sobaler AM, et al. Protein-energy wasting syndrome in advanced chronic kidney disease: prevalence and specific clinical characteristics. Nefrologia. 2018 Mar/Apr;38(2):141-51.,7171 Hasheminejad N, Namdari M, Mahmoodi MR, Bahrampour A, Azmandian J. Association of handgrip strength with malnutrition-inflammation score as an assessment of nutritional status in hemodialysis patients. Iran J Kidney Dis. 2016 Jan;10(1):30-5.. Each definition of malnutrition validated for this group of patients includes different sets of criteria. Therefore, prevalence may vary and comparison is potentially hampered. Besides, with standardization in mind, the definition of malnutrition cannot apply only to individuals with CKD. In order to strengthen medical practice and research, validated terms and criteria applicable beyond kidney disease must be defined.

PEW and sarcopenia are the terms more commonly related to malnutrition in individuals with CKD. In the NCPT, sarcopenia is not a diagnosis of malnutrition, but rather an element related to signs and symptoms gathered during Assessment and Reassessment. PEW has not been included in the NCPT, and since it applies only to patients with CKD, it cannot be included in SNOMED.

The NCPT separates the diagnosis of malnutrition into three categories based on etiology, as established in the international standardization proposal put forward by the Academy/ASPEN (American Society of Parenteral and Enteral Nutrition) in 20127272 White JV, Guenter P, Jensen G, Malone A, Shofield M; Academy Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012 May;36(3):275-83.. Focus in etiology is given to the inflammatory process, a common finding in CKD closely related to malnutrition and patient death.

In 2017, the guidelines of the ESPEN (European Society for Clinical Nutrition and Metabolism) posited that malnutrition might be further divided into four categories:7373 Cederholm T, Barazzonib R, Austincy P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36(1):49-64. 1) associated with chronic disease or condition with ongoing inflammation; 2) associated with chronic disease with minimal or undetected inflammation; 3) associated with acute disease or injury with severe inflammation; and 4) associated with chronic low food intake unrelated to the disease. The definitions and categories in the ESPEN apply to patients with CKD in various stages of the disease and care center types (e.g.: clinics, hospitals, outpatient clinics). Therefore, they may be recommended in standardization.

Comments

Several malnutrition diagnostic tools have been proposed and validated for patients with CKD. The SGA has been validated multiple times for all stages of CKD7474 Dai L, Mukai H, Lindholm B, Heimbürguer O, Barany P, Stenvinkel P, et al. Clinical global assessment of nutritional status as predictor of mortality in chronic kidney disease patients. PLoS One. 2017 Dec;12(12):e0186659.,7575 Paudel K, Visser A, Burke S, Samad N, Fan SL. Can bioimpedance measurements of lean and fat tissue mass replace subjective global assessments in peritoneal dialysis atients?. J Ren Nutr. 2015 Nov;25(6):480-7..

In addition, a number of tools stemmed from the traditional SGA, including the Patient Generated Subjective Global Assessment (PG-SGA), validated for individuals on HD7676 Desbrow B, Bauer J, Blum C, Kandasamy A, McDonald A, Montgomery K. Assessment of nutritional status in hemodialysis patients using patient-generated subjective global assessment. J Ren Nutr. 2005 Apr;15(2):211-6., and some added specific data, such as the 7-point SGA7777 Kalantar-Zadeh K, Kleiner M, Dunne E, Lee GH, Luft FC. A modified quantitative subjective global assessment of nutrition for dialysis patients. Nephrol Dial Transplant. 1999 Jul;14(7):1732-8.,7878 Santin F, Rodrigues J, Brito FB, Avesani CM. Performance of subjective global assessment and malnutrition inflammation score for monitoring the nutritional status of older adults on hemodialysis. Clin Nutr. 2018 Apr;37(2):604-11.. This scale disregards edema and considers years on dialysis and presence of comorbidities instead. Another offshoot is the Malnutrition-Inflammation Score (MIS)7878 Santin F, Rodrigues J, Brito FB, Avesani CM. Performance of subjective global assessment and malnutrition inflammation score for monitoring the nutritional status of older adults on hemodialysis. Clin Nutr. 2018 Apr;37(2):604-11.

79 Kalantar-Zadek K, Kopple JD, Block G, Humphreys MH. A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis. 2001 Dec;38(6):1251-63.

80 Borges MC, Vogt BP, Martin LC, Caramori JCT. Malnutrition inflammation score cut-off predicting mortality in maintenance hemodialysis patients. Clin Nutr ESPEN. 2017 Feb;17:63-7.

81 Wang WL, Liang S, Zhu FL, Liu JQ, Chen XM, Cai GY. Association of the malnutrition-inflammation score with anthropometry and body composition measurements in patients with chronic kidney disease. Ann Palliat Med. 2019;8(5):596-603.

82 Aggarwal HK, Jain D, Chauda R, Bhatia S, Sehgal R. Assessment of malnutrition inflammation score in different stages of chronic kidney disease. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2018 Dec;39(2-3):51-61.
-8383 Cupisti A, D'Alessandro C, Caselli GM, Egidi MF, Bottai A, Onnis FE, et al. Nutritional and functional assessment of peritoneal dialysis patients in the clinical practice: report from MITO-DP Group. G Ital Nefrol. 2016 Jul/Aug;33(4):gin/33.4.6., in which three items were added: the body mass index (BMI), serum albumin, and total iron-binding capacity.

Additionally, results from the Mini Nutritional Assessment Long-Form (MNA-LF)8484 Erdoğan E, Tutal E, Uyar ME, Bal Z, Demirci BG, Sayin B, et al. Reliability of bioelectrical impedance analysis in the evaluation of the nutritional status of hemodialysis patients - a comparison with mini nutritional assessment. Transplant Proc. 2013;45(10):3485-88.,8585 Rogowski L, Kusztal M, Golebiowski T, Bulinska K, Zembron-Lacny A, Wyka J, et al. Nutritional assessment of patients with end-stage renal disease using the MNA scale. Adv Clin Exp Med. 2018 Aug;27(8):1117-23. and the Nutritional Competence Score (NCS)8686 Thijssen S, Wong MM, Usvyat LA, Xiao Q, Kotanko P, Maddux FW. Nutritional competence and resilience among hemodialysis patients in the setting of dialysis initiation and hospitalization. Clin J Am Soc Nephrol. 2015 Sep;10(9):1593-601.,8787 Ye X, Dekker MJE, Maddux FW, Kotanko P, Konings CJAM, Raimann JG, et al. Dynamics of nutritional competence in the last year before death in a large cohort of US hemodialysis patients. J Ren Nutr. 2017 Nov;27(6):412-20. have been associated with mortality of patients with CKD. Associations have been reported between the Objective Score of Nutrition on Dialysis (OSND) and the MIS8888 Beberashvili I, Azar A, Sinuani I, Yasur H, Feldman L, Averbukh Z, et al. Objective score of nutrition on dialysis (OSND) as an alternative for the malnutrition-inflammation score in assessment of nutritional risk of haemodialysis patients. Nephrol Dial Transplant. 2010 Aug;25(8):2662-71.. Significant correlations have been described between the Integrative Clinical Nutrition Dialysis Score (ICNDS) and the SGA88 Lynn MR. Determination and quantification of content validity. Nurs Res. 1986 Nov/Dec;35(6):382-5.)(99 Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008 Apr;336(7650):924-6.. PEW criteria have also been used to diagnose malnutrition9090 Fouque D, Kalantar-Zadeh K, Kopple J, Cano N, Chauveau P, Cuppari L, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int. 2008 Feb;73(4):391-8.. Associations have been reported between PEW and SGA results and mortality of patients on dialysis9191 Leinig CE, Moraes T, Ribeiro S, Riella MC, Olandoski M, Martins C, et al. Predictive value of malnutrition markers for mortality in peritoneal dialysis patients. J Ren Nutr. 2011 Mar;21(2):176-83..

The KDOQI recommends the 7-point SGA for patients with CKD stage 5 and the MIS for individuals on HD and patients in post-transplant care3636 Ikizler TA, Burrowes J, Byham-Gray L, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020 Sep;76(3 Suppl 1):S1-S107.. However, since they are specific for individuals with CKD, these tools cannot meet the universality requirement. The NCPT recommends the SGA, the PG-SGA, and the MNA-LF for adult populations. The ESPEN7373 Cederholm T, Barazzonib R, Austincy P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36(1):49-64. recommends these tools for patient populations. However, if standardization is the target, using different tools becomes unpractical.

Although adjustments are often made to existing tools and new ones are constantly being developed, the traditional SGA is cited in every guideline, since it has been validated for different populations and care center types, even after modifications. The lack of universal acceptance of the SGA might be due to uncertainties tied to its subjective nature.

The Global Leadership Initiative on Malnutrition (GLIM)9292 Cederholm T, Jensen G L, Correia M, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition - a consensus report from the global clinical nutrition community. Clin Nutr. 2019 Feb;38(1):1-9. involved the four largest international clinical nutrition societies and developed a consensus document on practical indicators to diagnose various forms of malnutrition in different target populations and care center types. In the GLIM, at least one phenotypic criterion and one etiologic criterion must be met for an individual to be diagnosed with malnutrition. Phenotypic criteria include non-volitional weight loss, low body mass index, and reduced muscle mass. Etiologic criteria include reduced food intake or assimilation and inflammation or disease burden. The GLIM was not designed as a measurement tool, but as a diagnostic framework. However, its criteria and severity cutoff points have not been validated9393 Keller H, Van Der Schueren MAE, Jensen GL, Barazzoni R, Compher C, Correia MITD, et al. Global leadership initiative on malnutrition (GLIM): guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults. J Parenter Enteral Nutr. 2020 Aug;44(6):902-1003. DOI: https://doi.org/10.1002/jpen.1806
https://doi.org/10.1002/jpen.1806...
. With the exception of kidney transplant patients and individuals with early-stage CKD, the inclusion of BMI cutoff points may decrease specificity. Evidence indicates the existence of an epidemiologically counter-intuitive association (a negative association) between having a high BMI and mortality of patients with kidney disease and individuals on HD in particular3636 Ikizler TA, Burrowes J, Byham-Gray L, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020 Sep;76(3 Suppl 1):S1-S107., which might hamper the creation of different BMI cutoff points for different patient populations. Therefore, the BMI cannot be regarded as a universal criterion.

The MCC is a less subjective tool than the SGA7272 White JV, Guenter P, Jensen G, Malone A, Shofield M; Academy Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012 May;36(3):275-83.. It uses the three categories of malnutrition based on etiology (Chart 4). The MCC does not include the BMI or serum albumin as indicators, but agrees with the GLIM criteria and is based on a consistent definition of malnutrition. Besides, all indicators included in the MCC were recommended by the KDOQI3636 Ikizler TA, Burrowes J, Byham-Gray L, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020 Sep;76(3 Suppl 1):S1-S107. for the assessment of malnutrition of patients with CKD.

Chart 4
Clinical characteristics of malnutrition in adults: Academy and ASPEN criteria

Studies reported satisfactory levels of accuracy and moderate agreement for the MCC compared to the SGA in adult hospitalized patients9494 Hipskind P, Rath M, JeVenn A, Galang M, Nawaya A, Smith E, et al. Correlation of new criteria for malnutrition assessment in hospitalized patients: AND-ASPEN versus SGA. J Am Coll Nutr. 2020 Aug;39(6):518-27., individuals with severe conditions in general, trauma9595 Ceniccola GD, Okamura AB, Sepulveda Neta JDS, Lima FC, Deus ACS, Oliveira JA, et al. Association between AND-ASPEN malnutrition criteria and hospital mortality in critically Ill trauma patients: a prospective cohort study. JPEN J Parenter Enteral Nutr. 2020 Sep;44(7):1347-54., and surgery patients9696 Abahuje E, Niyongombwa I, Karenzi D, Bisimwa JD, Tuyishime E, Nterenganya F, et al. Malnutrition in acute care surgery patients in Rwanda. World J Surg. 2020 May;44(5):1361-7.. In regard to outcomes, the MCC predicted longer hospitalization times9797 Guerra RS, Fonseca I, Pichel F, Restivo MT, Amaral TF. Usefulness of six diagnostic and screening measures for undernutrition in predicting length of hospital stay: a comparative analysis. J Acad Nutr Diet. 2015 Jun;115(6):927-38. and higher care costs9898 Guerra RS, Sousa AS, Fonseca I, Pichel F, Restivo MT, Ferreira S, et al. Comparative analysis of undernutrition screening and diagnostic tools as predictors of hospitalisation costs. J Hum Nutr Diet. 2016 Apr;29(2):165-73.. In patients submitted to abdominal cancer surgery, higher degrees of malnutrition assessed by the MCC were associated with longer hospitalization, higher cost of care, higher hospital mortality, more severe complications, and higher readmission rates9999 Mosquera C, Koutlas NJ, Edwards KC, Strickland A, Vohra NA, Zervos EE, et al. Impact of malnutrition on gastrointestinal surgical patients. J Surg Res. 2016 Sep;205(1):95-101.. Similar results were obtained in retrospective studies with inpatients in general100100 Hiller LD, Shaw RF, Fabri PJ. Difference in composite end point of readmission and death between malnourished and nonmalnourished Veterans assessed using Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Clinical Characteristics. J Parenter Enteral Nutr. 2017 Nov;41(8):1316-24.,101101 Hudson L, Chittams J, Griffith C, Compher C. Malnutrition identified by Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition is associated with more 30-day readmissions, greater hospital mortality, and longer hospital stays: a retrospective analysis of nutrition assessment data in a major medical center. JPEN J Parenter Enteral Nutr. 2018 Jul;42(5):892-7.. Malnutrition assessed by the MCC was also associated with long term mortality (within up to two years) of elderly patients with pneumonia102102 Yeo HJ, Byun KS, Han J, Kim JH, Lee SE, Yoon SH, et al. Prognostic significance of malnutrition for long-term mortality in community-acquired pneumonia: a propensity score matched analysis. Korean J Intern Med. 2019 Jul;34(4):841-9.. Studies performed in ICU settings showed that MCC results were good predictors of death and length of hospitalization103103 Ceniccola GD, Holanda TP, Pequeno RSF, Mendonça VS, Oliveira ABM, Carvalho LSF, et al. Relevance of AND-ASPEN criteria of malnutrition to predict hospital mortality in critically ill patients: a prospective study. J Crit Care. 2018 Apr;44:398-403.,104104 Hiura G, Lebwohl B, Seres DS. Malnutrition diagnosis in critically ill patients using 2012 Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition standardized diagnostic characteristics is associated with longer hospital and intensive care unit length of stay and increased in-hospital mortality. JPEN J Parenter Enteral Nutr. 2020 Feb;44(2):256-64.. A prospective study enrolling 600 adult and elderly hospitalized subjects reported concurrent and predictive validity for the MCC even without using the hand grip strength test105105 Burgel CF, Teixeira PP, Leites GM, Carvalho GDN, Modanese PVG, Rabito EI, et al. Concurrent and predictive validity of AND-ASPEN malnutrition consensus is satisfactory in hospitalized patients: a longitudinal study. JPEN J Parenter Enteral Nutr. 2020 Aug 01; [Epub ahead of print]. DOI: https://doi.org/10.1002/jpen.1980
https://doi.org/10.1002/jpen.1980...
. The causes of hospitalization revolved primarily around chronic ailments including cancer, heart and lung diseases, and gastrointestinal disorders. The MCC showed good agreement and satisfactory levels of accuracy compared to the SGA for endpoints length of hospitalization, hospital deaths, readmission, and mortality within six months of discharge. In elderly patients on follow-up care after acute disease, MCC results were also associated with length of hospitalization and functional capacity106106 Sanchez-Rodriguez D, Marco E, Ronquillo-Moreno N, Maciel-Bravo L, Gonzales-Carhuancho A, Duran X, et al. ASPEN-AND-ESPEN: a postacute-care comparison of the basic definition of malnutrition from the American Society of Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics with the European Society for Clinical Nutrition and Metabolism definition. Clin Nutr. 2019 Feb;38(1):297-302..

To our knowledge, no studies have been published on the applicability of the MCC to patients with CKD. However, after analyzing the literature, it is likely that this tool might be valid for the population at hand.

Comments

Table 3 lists the terms used in Nutrition Intervention the experts selected. Nutrition Intervention in the NCP includes a set of behaviors and specific action either performed, delegated, coordinated, or recommended by a nutritionist5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14.. Intervention helps patients to resolve or improve from their problem. It is subdivided into two interconnected stages: planning and implementation.

Table 3
Nutrition Intervention Terms deemed essential by nutritionists specialized in chronic kidney disease

The planning stage includes the dietary prescription and the nutrition intervention goals. It is preferable that nutritionists and their patients define the two jointly. Goals must be attainable, measurable, and related to the condition the patient has been diagnosed with. The development of the care plan must be based on evidence-based care guidelines and other references, so that the expected patient-focused results are achieved in each point of the nutrition diagnosis. The plan also sets out the time and frequency of care, along with the resources needed to achieve the established goals.

During implementation, the nutritionist in charge defines the interventions, selects appropriate strategies, discusses ideas with the patient, and implements the plan. Based on the patient's condition, length of treatment and monitoring are defined and additional materials are developed.

Several intervention strategies may be recommended for patients with CKD, with the primary goal of preventing or reversing situations of malnutrition. Individualized ongoing education and counseling on nutrition are of the essence to prevent malnutrition and fluid, vitamin, and mineral imbalances in patients with CKD107107 Obi Y, Qader H, Kovesdy CP, Kalantar-Zadeh K. Latest consensus and update on protein-energy wasting in chronic kidney disease. Curr Opin Clin Nutr Metab Care. 2015 May;18(3):254-62..

Comments

The standard reference for daily nutrient intake guides Assessment and Reassessment (quantitative adjustment analysis) and Intervention (diet planning and prescription) in the NCP. Nutritionists may select the most adequate standard reference to define individualized goals based on professional judgment.

For healthy individuals and conditions lacking specific nutrient intake recommendations, the most widely used standard reference is the DRIs (Dietary Reference Intakes)108108 Institute of Medicine (US). Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary references intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington: National Academy Press (US); 1997.

109 Institute of Medicine (US). Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary references intakes for thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington: National Academy Press (US); 1998.

110 Institute of Medicine (US). Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary references intakes for vitamin c, vitamin e, selenium, and carotenoids. Washington: National Academy Press (US); 2000.

111 Institute of Medicine (US). Panel on Micronutrients. Dietary references intakes for vitamin a, vitamin k, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington: National Academy Press (US); 2001.

112 Trumbo P, Schlicker S, Yates AA, Poos M; Food and Nutrition Board of the Istitute of Medicie (US). Dietary references intakes for energy, carbohydrate, fiber, protein and amino acids. J Am Diet Assoc. 2002 Nov;102(11):1621-30.

113 Institute of Medicine (US). Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Washington: National Academy Press (US); 2004.
-114114 Institute of Medicine (US). Committee to Reviwe Dietary Reference Intakes. Dietary references intakes for calcium and vitamin D. Washington: National Academy Press (US); 2011.. For metabolically stable patients with CKD, this consensus document recommends the Clinical Practice Guideline for Nutrition in Chronic Disease3636 Ikizler TA, Burrowes J, Byham-Gray L, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020 Sep;76(3 Suppl 1):S1-S107. (Chart 5) as the standard reference for daily nutrient intake. The guidelines are part of the KDOQI developed by the National Kidney Foundation and the Academy.

Chart 5
References for daily nutrient intake for patients with chronic kidney disease

Tools such as My Plate, the Mediterranean Diet Pyramid115115 Serra-Majem L, Ortiz-Andrellucchi A, Sánchez-Villegas A. Mediterranean diet. In: Ferranti P, Berry EM, Anderson JR, eds. Encyclopedia of food security and sustainability. Amsterdam: Elsevier; 2019. v. 2. p. 292-301., and the DASH (Dietary Approaches to Stop Hypertension) Diet may be used as references for daily food intake for patients with CKD stages 1-5. The same tools may be easily adjusted to meet the needs of patients on HD or PD.

Comments

Monitoring and Evaluation is the last step in the NCP5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14.. It includes three elements: monitoring, measurement, and evaluation of the changes in signs and symptoms (Assessment and Reassessment indicators).

Nutrition Monitoring and Evaluation includes the examination of post-intervention outcomes, the selection of quality indicators derived from evidence-based, best practice guidelines5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14.. Indicators use available data to provide quantitative measures of the desired targets. The need for Reassessment is defined during Monitoring and Evaluation5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14..

The standardized terminology for Nutrition Monitoring and Evaluation is the same used in Assessment and Reassessment (Table 1), with the exception of the terms used in Client History (50 terms).

Recommendations for the outcome management system

Comments

The NCP requires documentation so that patient care can be monitored and assessed and proper support given to outcome management systems. Documents in standardized format optimize quality management and enable performance assessment.

The elements comprised in the ADIME acronym are as follows: "Assessment/ Reassessment (A), Diagnosis (D), Intervention (I), and Monitoring/Evaluation (ME)"3939 Academy of Nutrition and Dietetics (AND). International collaboration and translations. Nutrition terminology reference manual (eNCPT): dietetics language for nutrition care [Internet]. Chicago: AND; 2005; [access in 2020 Mar 20]. Available from: http://www.ncpro.org/international-collaboration
http://www.ncpro.org/international-colla...
. In "D", it is recommended that a PES (problem; etiology; signs and symptoms) statement be produced3939 Academy of Nutrition and Dietetics (AND). International collaboration and translations. Nutrition terminology reference manual (eNCPT): dietetics language for nutrition care [Internet]. Chicago: AND; 2005; [access in 2020 Mar 20]. Available from: http://www.ncpro.org/international-collaboration
http://www.ncpro.org/international-colla...
. The term "related to" should be placed next to the problem label to identify the cause of the problem. The etiology (cause) is made up of the factors that contribute to the existence of the problem.

The identification of the etiology leads to the selection of intervention, which purpose is to resolve the nutrition problem. Signs and symptoms (indicators) are the elements that define whether the patient presents with a specific nutrition problem. They are connected to etiology by the words "as evidenced by."

The ADIME acronym has not been officially standardized to document he NCP, but it has been recommended on account of its practicality and ease-of-use. Regardless of format, documentation must be clear, accurate, concise, specific, limited to one problem at a time, and precisely related to etiology and information collected during nutrition assessment. It should contain as little free text as possible to facilitate comparisons and analysis of performance indicators.

Comments

The Outcome Management System also supports the NCP5353 Swan WI, Vivanti A, Hakel-Smith NA, Hotson B, Orrevall Y, Trostler N, et al. Nutrition care process and model update: toward realizing people-centered care and outcomes management. J Acad Nutr Diet. 2017 Dec;117(12):2003-14. and is operated by individuals with different backgrounds. It is responsible for supporting ongoing quality improvement and is extremely important in any care environment.

An Outcome Management System defines the indicators used to reflect the current status of a problem to compare it against a predefined ideal status or established realistic improvement goal. Goals must be identified based on the reality of each institution. They must be challenging, but possible to achieve. They must also be constantly adjusted (reviewed) against achieved results.

Calculations and comparison of management indicators identify the actions required to improve the quality of the services delivered. Key and specific indicators in nutrition must reflect solely what must be improved through the work of nutritionists. Other indicators must be considered jointly with a multidisciplinary team for opportunities to improve service in general.

The standardization of the NCPT in electronic patient chart systems allows documentation in a structured format. Workflows and tools used in this task have been published for adult and pediatric practices116116 Kight CE, Bouche JM, Curry A, Frankenfield D, Good K, Guenter P, et al. Consensus recommendations for optimizing electronic health records for nutrition care. Nutr Clin Pract. 2020 Feb;120(7):1227-37.. Data entries with minimal free text (structured patient chart) allows for quick access, less ambiguity and more specificity, and confinement within evidence-based parameters. Consequently, outcome management is facilitated, care efficiency increased, and nutrition outcomes are improved4545 Rossi M, Campbell KL, Ferguson M. Implementation of the nutrition care process and international dietetics and nutrition terminology in a single-center hemodialysis unit: comparing paper vs electronic records. J Acad Nutr Diet. 2014 Jan;114(1):124-30..

The Outcome Management System monitors the success of the implementation of the NCP and provides input and advice. The goal is to optimize the delivery of care by focusing on process quality, effectiveness, and efficiency. Management tools enable compliance verification and the identification of nonconformities. Chart 6 includes items usually available in practices involving patients with CKD and closely related to the NCP. Most have had their relevance acknowledged in the KDOQI3636 Ikizler TA, Burrowes J, Byham-Gray L, Campbell KL, Carrero JJ, Chan W, et al. KDOQI Nutrition in CKD Guideline Work Group. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020 Sep;76(3 Suppl 1):S1-S107. and were included in the recommendations of the guidelines of the American Diabetes Association117117 American Diabetes Association (ADA). 6. Glycemic targets: standards of medical care in diabetes - 2019. Diabetes Care. 2019;42(Suppl 1):S61-S70.. Since nutrition is a high risk factor in this population, it is recommended that it be analyzed in terms of severity for different age ranges.

Chart 6
Quality management indicators recommended for nutrition care of patients with chronic kidney disease

Conclusion

Standardizing terminology does not mean that the same care measures will be provided to every patient. Tailoring care to patient needs and values and using the best evidence available to make decisions are still required.

However, standardization inevitably introduces changes to practice. It is a relevant factor in clinical assessment and facilitates the documentation and management of the outcomes derived from nutrition care. Standardization allows the introduction of information systems in data collection and analysis, thereby strengthening the bridges between technology, practice, and research.

Once the learning curve has been overcome, the implementation of the NCPT and screening and assessment tools introduces significant opportunities to improve the effectiveness of nutrition services. Care is improved in terms of service and outcomes; communication between health care workers and institutions is enhanced; priorities in intervention plans are optimally assigned; realistic, measurable goals can be set; the documentation of patient charts is improved; services are better managed and outcomes more clearly understood; payments for procedures is facilitated; specific contributions coming from nutritionists in patient care are viewed more clearly and appreciated by the care team and the community.

To sum up with, standardization in nutrition brings significant progress in practice, education, research, and regulation. It is certainly the most effective way to show the impact nutrition care has in the health of individuals with CKD.

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Publication Dates

  • Publication in this collection
    09 Apr 2021
  • Date of issue
    Apr-Jun 2021

History

  • Received
    22 Sept 2020
  • Accepted
    07 Dec 2020
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