Renal Telenutrition for Kidney Health: Leveraging Telehealth and Telemedicine for Nutritional Assessment and Dietary Management of Patients With Kidney Disorders

Abstract

Telehealth refers to the delivery of healthcare services from a distance using telecommunication techniques such as video and audio, mostly in real time but across different locations. During the COVID-19 pandemic in 2020, mandated social distancing has led to reinvigoration and colossal expansion of telehealth. Telehealth is expected to continue through 2021 and even after COVID-19 pandemic is overcome, given its many advantages including its exceptional level of patients' and providers' convenience and high level of efficiency, while reimbursements remain comparable to in-person visits. However, there are undeniable drawbacks including inability to provide a real physical examination with verifiable vital signs including objective weight and height recording and missing auscultation and percussion along with all other touch-dependent components of an actual patient visit. There are technical challenges including timely connection for a tightly scheduled appointment and time lost during connection setup, video and voice issues, sporadic loss of connection, slow video stream from bandwidth restrictions, etc. Even if all these technical issues are resolved or compensated for by other means, there is something inherent to real face-to-face visit that may not be replaced by telehealth approaches. Nevertheless, telehealth technology is here to stay and expand, with or without pandemics or other disasters from climate change. Hence, most healthcare providers and clinical researchers welcome and embrace telehealth. Telehealth has different domains including telemedicine and telenutrition, which are usually provided by physicians and dietitians, respectively. Telemedicine is a well-rooted and constantly expanding and evolving operation, whereas telenutrition is somewhat less recognized; while in 2020, it has been practiced increasingly more frequently by many dietitians including in renal nutrition.1Peregrin T. Telehealth is transforming health care: what you need to know to practice telenutrition.J Acad Nutr Diet. 2019; 119: 1916-1920Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar According to the Academy of Nutrition and Dietetics, telenutrition involves the interactive use, by a registered dietitian nutritionist, of electronic information and telecommunications technologies to implement the nutrition care process, including nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care, and nutrition monitoring and evaluation, with patients or clients at a remote location, within the provisions of their state licensure as applicable.1Peregrin T. Telehealth is transforming health care: what you need to know to practice telenutrition.J Acad Nutr Diet. 2019; 119: 1916-1920Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,2Academy of Nutrition and Dietetics (AND)Practicing telehealth.Practice-Resources. 2020; (https://www.eatrightpro.org/practice/practice-resources/telehealth/practicing-telehealth. Accessed October 10, 2020.): 2020Google Scholar Even before COVID pandemic, telenutrition was used as an innovative approach to adapt weight loss interventions.3Kuzmar I.E. Cortes-Castell E. Rizo M. Effectiveness of telenutrition in a women's weight loss program.PeerJ. 2015; 3: e748Crossref Scopus (6) Google Scholar,4Ventura Marra M. Lilly C.L. Nelson K.R. Woofter D.R. Malone J. A pilot randomized controlled trial of a telenutrition weight loss intervention in middle-aged and older men with multiple risk factors for cardiovascular disease.Nutrients. 2019; 11: 229Crossref Scopus (24) Google Scholar In recent months, there has been a tsunami-like growth in the use of telenutrition in kidney care. We define "renal telenutrition" as the use of telehealth in nutritional and dietary management of kidney health and kidney disease by a registered dietitian or other nutrition professionals and expect that this new and fast expanding field will continue to evolve to become the prevailing facet of many activities that renal dietitians and other nutrition and dietetic professionals will be involved in care of patients with kidney health–related problems. Renal telenutrition assessments include two main domains:(1)Assessment of the nutritional status of patients with chronic kidney disease (CKD) including those under dialysis therapy or kidney transplantation. The two core assessment tools used in renal nutrition include the Subjective Global Assessment (SGA) of Nutrition and the Malnutrition-Inflammation Score (MIS, Kalantar Score),5Obi Y. Qader H. Kovesdy C.P. Kalantar-Zadeh K. Latest consensus and update on protein-energy wasting in chronic kidney disease.Curr Opin Clin Nutr Metab Care. 2015; 18: 254-262Crossref PubMed Scopus (166) Google Scholar, 6Slee A.D. Reid J. Wasting in chronic kidney disease – a complex issue.JCSM Clin Rep. 2018; 3: 1-10Google Scholar, 7Hanna R.M. Ghobry L. Wassef O. Rhee C.M. Kalantar-Zadeh K. A practical approach to nutrition, protein-energy wasting, Sarcopenia, and Cachexia in patients with chronic kidney disease.Blood Purif. 2020; 49: 202-211Crossref Scopus (85) Google Scholar and they both can be effectively implemented via telenutrition. The MIS has 10 components, each with a severity score of 0 (normal) to 3 (most severely malnourished), including the first seven components that are the fully quantitative versions of the seven SGA items (hence, running MIS can also generate an SGA score at the same time), including five nutrition history components (weight loss, food intake, gastrointestinal symptoms, functionality, and comorbidity); two nutritional physical examination components (fat loss and muscle loss), both of which can be assessed upon video visualization and description by the patient or care partner; body mass index as the 8th component of the MIS; and two laboratory values (albumin and transferrin).8Bakkal H. Dizdar O.S. Erdem S. et al.The relationship between hand grip strength and nutritional status determined by malnutrition inflammation score and biochemical parameters in hemodialysis patients.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (14) Google Scholar, 9Amparo F.C. Cordeiro A.C. Carrero J.J. et al.Malnutrition-inflammation score is associated with handgrip strength in nondialysis-dependent chronic kidney disease patients.J Ren Nutr. 2013; 23: 283-287Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 10Lopes M.B. Silva L.F. Lopes G.B. et al.Additional contribution of the malnutrition-inflammation score to predict mortality and patient-reported outcomes as compared with its components in a cohort of African descent hemodialysis patients.J Ren Nutr. 2017; 27: 45-52Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar In addition to the telenutrition-based assessment of nutritional status via the MIS, frailty including muscle mass and function can be assessed via telemedicine as well including handgrip strength or other components of the Fried Frailty Index11Fried L.P. Tangen C.M. Walston J. et al.Frailty in older adults: evidence for a phenotype.J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156Crossref PubMed Google Scholar using its telehealth compatible versions.12Papachristou E. Wannamethee S.G. Lennon L.T. et al.Ability of self-reported frailty components to predict incident disability, falls, and all-cause mortality: results from a population-based study of older British men.J Am Med Dir Assoc. 2017; 18: 152-157Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar,13Upatising B. Hanson G.J. Kim Y.L. Cha S.S. Yih Y. Takahashi P.Y. Effects of home telemonitoring on transitions between frailty states and death for older adults: a randomized controlled trial.Int J Gen Med. 2013; 6: 145-151Crossref Scopus (26) Google Scholar(2)Assessment of diet and food intake among patients with CKD: This can be done by interviewing patients on what they eat including 3-day diet record with supplementary diet interview (which for patients on hemodialysis should include one dialysis day and two surrounding no-dialysis days),14Mirza M. Shahsavarian N. St-Jules D.E. et al.Examining the dietary intake of hemodialysis patients on treatment days and nontreatment days.Top Clin Nutr. 2017; 32: 106-112Crossref Scopus (2) Google Scholar 24-hour diet recall including via phone, and food frequency questionnaires.15Kalantar-Zadeh K. Kovesdy C.P. Bross R. et al.Design and development of a dialysis food frequency questionnaire.J Ren Nutr. 2011; 21: 257-262Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Upon completion of these two core assessments of nutritional status and diet, the remainder of telenutrition including nutritional diagnosis, nutrition and dietary intervention with plan of care, and plans for periodic nutrition and diet monitoring and evaluation can be discussed during the telehealth session with the patient. Overall, telenutrition allows for specialized nutrition care to be delivered more cost-effectively and to more patients in need. Telenutrition can offer a useful means for clinical studies when there is heightened need for social distancing. In a study by Kelley et al16Kelly J.T. Campbell K.L. Hoffmann T. Reidlinger D.P. Patient experiences of dietary management in chronic kidney disease: a focus group study.J Ren Nutr. 2018; 28: 393-402Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar that examined the experiences of patients with CKD in managing dietary recommendations, including their perspectives on the use telehealth to support dietary management in CKD, the authors concluded that easy-to-use telehealth options had the potential to overcome the shortcomings in current health service delivery. Telehealth including telenutrition provides patients with CKD with pragmatic tools and comprehensible and consistent information which fosters ownership and self-monitoring.16Kelly J.T. Campbell K.L. Hoffmann T. Reidlinger D.P. Patient experiences of dietary management in chronic kidney disease: a focus group study.J Ren Nutr. 2018; 28: 393-402Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar In this issue of the Journal of Renal Nutrition (JReN), Bakkal et al8Bakkal H. Dizdar O.S. Erdem S. et al.The relationship between hand grip strength and nutritional status determined by malnutrition inflammation score and biochemical parameters in hemodialysis patients.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (14) Google Scholar examined the relationship between handgrip strength, using a hand dynamometer, and nutritional status by the MIS (Kalantar Score) and biochemical measures in 132 patients on hemodialysis in Turkey, who have been on hemodialysis treatment for at least 6 months. The authors reported that the lower the handgrip strength, the higher the MIS value as a sign of a more severe malnutrition. They also found that only the MIS had a statistically significant impact on handgrip strength in the regression models.8Bakkal H. Dizdar O.S. Erdem S. et al.The relationship between hand grip strength and nutritional status determined by malnutrition inflammation score and biochemical parameters in hemodialysis patients.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (14) Google Scholar It remains to be determined if similar MIS-based investigations can be reciprocated by means of telehealth technology. Given 6-8 times greater in-hospital mortality rate of patients on dialysis than nondialysis population and given the potential role frailty may play in poor outcomes of these patients, Jiang et al17Jiang X. Li D. Shen W. Shen X. Liu Y. In-hospital outcomes of patients on maintenance dialysis with frailty: 10-year results from the US national inpatient sample database.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (3) Google Scholar examined national data of 1,424,026 hospitalized maintenance dialysis patients between 2005 and 2014, who were classified based on frailty status. The investigators found that hospitalized dialysis patients with frailty had 5 days longer hospital stays, incurred $40,000 more in-hospital costs, and were at double the risk of in-hospital mortality and three times the risk of discharge to long-term facilities than those without frailty. Of note, the impact of frailty on these outcomes was even greater among patients on dialysis younger than 65 years. Hence, accurate assessment of frailty including via telehealth and development of adequate interventions for frailty including via telenutrition are of high priority. Given that the appropriate dietary protein intake target range for patients on hemodialysis with frailty is less clear, Hasegawa et al18Hasegawa J. Kimachi M. Kurita N. Kanda E. Wakai S. Nitta K. The normalized protein catabolic rate and mortality risk of patients on hemodialysis by frailty status: the Japanese dialysis outcomes and practice pattern study.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (4) Google Scholar examined calculated normalized protein catabolic rate, a urea kinetic–based surrogate of dietary protein intake, in a longitudinal study of 2,404 patients on hemodialysis from the Japanese Dialysis Outcomes and Practice Pattern Study. Patients in the low–normalized protein catabolic rate group, i.e., lowest dietary protein intake, showed a higher prevalence of frailty. Although mortality data were not significantly different, these data suggest a clinically relevant association between dietary protein intake and frailty in patients on dialysis. Yamamoto et al19Yamamoto S. Matsuzawa R. Kamitani T. et al.Efficacy of exercise therapy initiated in the early phase after kidney transplantation: a pilot study.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (2) Google Scholar examined the efficacy of a supervised exercise therapy protocol starting immediately after kidney transplantation to prevent or correct frailty. They compared 10 patients with usual care plus exercise training comprised of supervised aerobic training and physical activity instruction from day 6 to 2 months after kidney transplantation, versus 14 patients with usual care alone. At 2 months, the exercise therapy group showed significant improvement in 6-minute walking distance and isometric knee extensor strength. Hence, supervised aerobic training and physical activity instructions initiated in the early phase after transplantation may improve physical performance. Suresh et al20Suresh A. Robinson L. Milliron B.J. et al.Approaches to obesity management in dialysis settings: renal dietitian perspectives.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (5) Google Scholar studied the perspectives of 118 renal dietitians on different approaches to obesity management for dialysis-dependent patients using an online 21-item survey that was distributed via individual outreach and a professional organization e-mail Listserv. More than 90% of responding dietitians indicated that kidney transplantation goal was the main reason that patients on dialysis with obesity sought weight loss interventions. Calorie restriction was rated as the most common weight loss approach. Exercise, diet counseling, and stress management were variably prioritized as weight loss management strategies. Barriers to obesity management in dialysis settings included lack of time, lack of training in weight loss counseling, and gaps in current renal nutritional guidelines.20Suresh A. Robinson L. Milliron B.J. et al.Approaches to obesity management in dialysis settings: renal dietitian perspectives.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (5) Google Scholar This study also provides a relevant example of an exclusively online conducted investigation that did not require in-person contact and therefore in line of the social distancing requirements for research conduct under COVID-19 pandemic. In this issue of JReN, there are three studies related to dietary phosphorus and fibroblast growth factor-23 (FGF-23). Anand et al21Anand S. Jagannathan R. Gupta R. Mohan S. Prabhakaran D. Wolf M. Fibroblast growth factor-23 and a vegetarian diet.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (2) Google Scholar measured 24-hour urinary phosphorus and serum FGF-23 in 1,192 study participants in rural and urban India including 70 urban nonvegetarians, 564 urban vegetarians, and 558 rural vegetarians and found that urinary phosphorus excretion was higher in rural than in urban vegetarians (503 vs. 365 mg/day), while FGF-23 levels did not differ by residence or dietary preference. Pool et al22Pool L.R. Kershaw K.N. Gordon-Larsen P. et al.Racial differences in the associations between food insecurity and fibroblast growth factor 23 in the coronary artery risk development in young adults study.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (4) Google Scholar examined racial differences in the associations between food insecurity and FGF-23 in a large multisite cohort including 3,421 black and white participants with follow-up time of 20 to 30 years, who were enrolled in the study between the ages of 18 and 30 years. During follow-up period, 29% of blacks and 14% of whites experienced change in food security. Developing food insecurity was associated with a 48% greater odds of increasing to the highest quartile of FGF-23 among blacks; the authors concluded that among blacks, food insecurity was associated with an increase in levels of FGF-23.22Pool L.R. Kershaw K.N. Gordon-Larsen P. et al.Racial differences in the associations between food insecurity and fibroblast growth factor 23 in the coronary artery risk development in young adults study.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (4) Google Scholar For more accurate assessment of dietary phosphorus load, Narasaki et al23Narasaki Y. Yamasaki M. Matsuura S. et al.Phosphatemic index is a novel evaluation tool for dietary phosphorus load: a whole-foods approach.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (5) Google Scholar developed a novel Phosphatemic Index (PI) based on phosphorus bioavailability and evaluated the effect of foods with different PIs in mixed meals on serum intact FGF-23 concentration. They found that ingestion of high PI test meals was associated with a higher serum FGF-23 and lower 1,25-dihydroxyvitamin D levels compared with ingestion of low PI test meals. If reproduced and validated in additional studies, the PI can emerge as a patient- and dietitian-centered tool to accurately evaluate the dietary phosphorus load of various foods and may help patients make appropriate food choices for dietary phosphorus control in patients with CKD.23Narasaki Y. Yamasaki M. Matsuura S. et al.Phosphatemic index is a novel evaluation tool for dietary phosphorus load: a whole-foods approach.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (5) Google Scholar Anadon-Ruiz et al24Anadon Ruiz A. Martin Jimenez E. Bermejo-Barrera P. Lozano R. Seijas V.M. Selenium and all-cause mortality in end-stage renal disease. Retrospective observational cohort study.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (4) Google Scholar examined a cohort of 85 patients undergoing three different types of dialysis modalities and found that patients, in whom a low selenium level was associated to nearly 3-fold higher death risk ratio than in patients with normal or high selenium (>118 mug/L). Interestingly, low-albumin patients of this cohort exhibited an almost six times higher likelihood of having a low serum selenium.24Anadon Ruiz A. Martin Jimenez E. Bermejo-Barrera P. Lozano R. Seijas V.M. Selenium and all-cause mortality in end-stage renal disease. Retrospective observational cohort study.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (4) Google Scholar In a proof-of-concept study by Viramontes-Horner et al25Viramontes Horner D. Willingham F.C. Selby N.M. Taal M.W. Impact of dietetic intervention on skin autofluorescence and nutritional status in persons receiving dialysis: a proof of principle study.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (5) Google Scholar on potential effect of dietetic intervention on skin autofluorescence, a correlate of advanced glycation end-products, in dialysis-dependent patents, dietetic support was associated with stable autofluorescence levels despite an increase in dietary advanced glycation end-product intake among 41 patients on hemodialysis and 8 patients on peritoneal dialysis under the study, suggesting that interventions to improve nutrition may be important in preventing the rise in skin autofluorescence observed in malnourished dialysis populations. In a qualitative study with semistructured interviews among 34 adults undergoing maintenance hemodialysis in a UK teaching hospital using audio-recorded, transcribed interviews, Morris and Lycett26Morris A. Lycett D. Experiences of the dietary management of serum potassium in chronic kidney disease: interviews with UK adults on maintenance hemodialysis.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (6) Google Scholar showed that the so-called low-potassium diets bring practical and psychosocial consequences with significant impact on the perception of living with kidney disease. Some patients experienced financial difficulties, and decisions were made to prioritize family needs over their own dietary prescriptions. The authors concluded that renal health professionals should offer more support to people on a low-potassium diet.26Morris A. Lycett D. Experiences of the dietary management of serum potassium in chronic kidney disease: interviews with UK adults on maintenance hemodialysis.J Ren Nutr. 2020; Abstract Full Text Full Text PDF Scopus (6) Google Scholar Sussman et al27Sussman E.J. Singh B. Clegg D. Palmer B.F. Kalantar-Zadeh K. Let them eat healthy: can emerging potassium binders help overcome dietary potassium restrictions in chronic kidney disease?.J Ren Nutr. 2020; Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar reviewed the contemporary literature on the evidence behind the prevailing dogma that although potassium-rich fresh fruits and vegetables provide many health benefits, there has long been the concern over presumable risk of hyperkalemia. The authors identified the unmet need for clinical trials including in patients on hemodialysis to compare the current standard of care or so-called "renal diet," which is a potassium-restricted diet, to a potassium-liberalized diet comprising abundant fresh fruits and vegetables combined with a potassium binder.27Sussman E.J. Singh B. Clegg D. Palmer B.F. Kalantar-Zadeh K. Let them eat healthy: can emerging potassium binders help overcome dietary potassium restrictions in chronic kidney disease?.J Ren Nutr. 2020; Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar

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