CHHS17/209 Canberra Hospital and Health Services Clinical Procedure Initiation of Very Low Energy Diets in Adults with severe Chronic Kidney Disease Contents Contents..................................................... 1 Purpose...................................................... 2 Scope........................................................ 2 Section 1 – Initiation process for Very Low Energy Diet......2 Section 2 – Risks of very low energy diets in severe chronic kidney disease and unit with primary responsibility for managing those risks.........................................3 Related Policies, Procedures, Guidelines and Legislation.....3 References................................................... 4 Definition of Terms..........................................5 Search Terms................................................. 6 Doc Number Version Issued Review Date Area Responsible Page CHHS17/209 1 05/09/2017 01/09/2019 Medicine 1 of 8 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
Transcript
CHHS17/209
Canberra Hospital and Health ServicesClinical ProcedureInitiation of Very Low Energy Diets in Adults with severe Chronic Kidney DiseaseContents
Section 1 – Initiation process for Very Low Energy Diet............................................................2
Section 2 – Risks of very low energy diets in severe chronic kidney disease and unit with primary responsibility for managing those risks.......................................................................3
Related Policies, Procedures, Guidelines and Legislation.........................................................3
Doc Number Version Issued Review Date Area Responsible PageCHHS17/209 1 05/09/2017 01/09/2019 Medicine 1 of 6
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS17/209
Purpose
The purpose of this procedure is to provide safe management of rapid weight loss from very low energy diets (VLED) when these are utilised in adults with severe chronic kidney disease (CKD). It sets out what is considered a reasonable minimum renal and obesity service follow-up interval to manage anticipated complications of rapid weight loss. For the purposes of this document severe chronic kidney disease is defined as any adult with an estimated glomerular filtration rate less than 30 mL/min/1.73m2.
Back to Table of Contents
Scope
This procedure applies to the following staff working within their scope of practice: Medical Officers Nurses Dieticians Students under direct supervision.
This procedure is targeted at patients of ACT Health Renal Service Network with stage 2 or 3 obesity that are being considered for a VLED by the ACT Health Obesity Management Service.
Back to Table of Contents
Section 1 – Initiation process for Very Low Energy Diet
1. Patient assessed by Obesity Management Service as suitable for a VLED. 2. Patient provided by Obesity Management Service with information detailing the
potential risks and benefits of a VLED. 3. Patients choosing to proceed with a VLED should be discussed with their usual renal
physician by the Obesity Management Service.4. Dialysis patients proceeding with a VLED are to be referred by their nephrologist to the
clinic manager at the Belconnen Health Centre Dialysis Clinic (the haemodialysis unit) and non-dialysis patients are to be referred to the Chronic Kidney Diseases Coordinator.
5. Renal service to arrange a weekly dialysis session (for patients already receiving haemodialysis) at the Belconnen Dialysis Clinic to commence when the VLED is initiated.
6. Renal Service to arrange weekly appointments with a nephrologist at the Belconnen Health Centre for dialysis patients, or fortnightly appointments at the Belconnen Health Centre for non-dialysis patients. These appointments are to be scheduled to commence on initiation of the VLED and to continue at this frequency for the duration of a VLED that is resulting in an estimated 2kg non-fluid weight loss/week or greater. If the patient’s usual nephrologist is unable to provide this frequency of review then, with the usual nephrologist’s permission, the Obesity Management Service may refer to a nephrologist that is able to provide this service.
Doc Number Version Issued Review Date Area Responsible PageCHHS17/209 1 05/09/2017 01/09/2019 Medicine 2 of 6
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS17/209
7. The patient commences a VLED as per normal Obesity Management Service Protocols.
Back to Table of Contents
Section 2 – Risks of very low energy diets in severe chronic kidney disease and unit with primary responsibility for managing those risks.
Table 1: Risks and risk reduction strategies when VLED is used in moderate to severe chronic kidney disease (eGFR ≤45mL/min/1.73m2 by CKD-EPI equation)
Risk Preventative Strategy Speciality Responsible
Action
Hypotension* Weekly BP monitoring and fortnightly physical examination, extended to monthly after 4 weeks if clinically appropriate.
Renal Adjustment of antihypertensives, euvolaemic weight target and diuretics as required.
Hypertension** Weekly assessment of haemodialysis record and assessment of volume status if haemodialysis record indicates a significant alteration in BP
Renal Adjustment of antihypertensives, euvolaemic weight target and diuretics as required.
Hyperuricosuria* Spot urine pH at baseline and weekly for 2 weeks preferably by urine dipstick performed at point of care
Renal Adjustment of alkalai therapy as required.
Electrolyte Disturbance and acute kidney injury
Weekly EUC Urate and CPM extended to monthly after 4 weeks if clinically appropriate
Renal Increase electrolytes that are too low, decrease electrolytes that are too high as clinically appropriate.
Hypo or hyperglycaemia
As per usual Obesity Service Practice
Obesity Increase or decrease hypoglycaemic medication as clinically appropriate.
* Applies only to non-dialysis CKD**Applies only to haemodialysis patients
Back to Table of Contents
Related Policies, Procedures, Guidelines and Legislation
Doc Number Version Issued Review Date Area Responsible PageCHHS17/209 1 05/09/2017 01/09/2019 Medicine 3 of 6
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS17/209
Policies Health Directorate Nursing and Midwifery Continuing Competence Policy Consent and Treatment Active Management of Larger (Bariatric) Adult Patients Policy
Guidelines Fasting Guidelines – Elective and Emergency Surgery
Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011
Back to Table of Contents
References
1. Nestle Health Science, Optifast® VLCDTM Clinical Treatment Protocol. Available at: https://webcache.googleusercontent.com/search?q=cache:NdqCyjceY3UJ:https://www.optifast.com.au/resources/protocols-and-guidelines/clinical-treatment-protocol+&cd=1&hl=en&ct=clnk&gl=au&client=firefox-b-ab. (Accessed: 17th May 2017)
2. Mann, J. F. et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. The Lancet 372, 547–553 (2008).
3. Klahr, S. et al. The Effects of Dietary Protein Restriction and Blood-Pressure Control on the Progression of Chronic Renal Disease. N. Engl. J. Med. 330, 877–884 (1994).
4. Malvy, D., Maingourd, C., Pengloan, J., Bagros, P. & Nivet, H. Effects of severe protein restriction with ketoanalogues in advanced renal failure. J. Am. Coll. Nutr. 18, 481–486 (1999).
5. Sigler, M. H. The mechanism of the natriuresis of fasting. J. Clin. Invest. 55, 377–387 (1975).
6. Colles, S. L., Dixon, J. B., Marks, P., Strauss, B. J. & O’Brien, P. E. Preoperative weight loss with a very-low-energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am. J. Clin. Nutr. 84, 304–311 (2006).
7. Tsai, A. G. & Wadden, T. A. The Evolution of Very-Low-Calorie Diets: An Update and Meta-analysis. Obesity 14, 1283–1293 (2006).
8. Amatruda, J. M., Richeson, J. F., Welle, S. L., Brodows, R. G. & Lockwood, D. H. The Safety and Efficacy of a Controlled Low-Energy (’Very-Low-Calorie’) Diet in the Treatment of Non-Insulin-Dependent Diabetes and Obesity. Arch. Intern. Med. 148, 873–877 (1988).
Doc Number Version Issued Review Date Area Responsible PageCHHS17/209 1 05/09/2017 01/09/2019 Medicine 4 of 6
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS17/209
9. Henry, R. R., Wiest-Kent, T. A., Scheaffer, L., Kolterman, O. G. & Olefsky, J. M. Metabolic consequences of very-low-calorie diet therapy in obese non-insulin-dependent diabetic and nondiabetic subjects. Diabetes 35, 155–164 (1986).
10. Friedman, A. N., Chambers, M., Kamendulis, L. M. & Temmerman, J. Short-Term Changes after a Weight Reduction Intervention in Advanced Diabetic Nephropathy. Clin. J. Am. Soc. Nephrol. 8, 1892–1898 (2013).
11. Lassemillante, A.-C. M., Oliver, V., Hickman, I., Murray, E. & Campbell, K. L. Meal replacements as a strategy for weight loss in obese hemodialysis patients. Hemodial. Int. 20, E18–E23 (2016).
12. Levey, A. S. et al. A new equation to estimate glomerular filtration rate. Ann. Intern. Med. 150, 604–12 (2009).
Back to Table of Contents
Definition of Terms
Severe chronic kidney diseaseEstimated GFR below 30 mL/min/1.73sqm body surface area as determined by the CKD-EPI equation12.
HypotensionThis is a blood pressure that is considered too low. What is considered too low depends on clinical judgement.
HypertensionThis is a blood pressure over 140mmHg systolic or over 90mmHg diastolic. Elimination of hypertension is not always a treatment target.
HyperuricosuriaThis is an excess (compared to the pathology laboratory reference range) daily excretion of uric acid and urate.
Electrolyte disturbanceThis is when an electrolyte in plasma or serum is either above, or below, the pathology laboratory reference range. Commonly measured electrolytes are magnesium, calcium, phosphorus, sodium, potassium, bicarbonate, urate, and chloride.
Acute Kidney InjuryThis is where the kidney suffers acute loss of function as defined for the purposes of this document as a rise in serum or plasma creatinine of more than 26 micromol/L
HypoglycaemiaThis is a blood sugar that is too low. What is considered too low for an individual patient depends on specific patient characteristics, however a plasma glucose <2.5 mmol/L is always too low.
Doc Number Version Issued Review Date Area Responsible PageCHHS17/209 1 05/09/2017 01/09/2019 Medicine 5 of 6
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
CHHS17/209
HyperglycaemiaThis is a blood sugar that is too high. What is considered too high depends on the post-prandial period and other patient characteristics such as age, com-morbidities and frailty. A blood sugar >11 mmol/L is always abnormal.
Back to Table of Contents
Search Terms
Diet, Chronic kidney disease, Very low energy, Very low calorie, kidney, haemodialysis, VLED, dialysis, CKD, obesity, management,
Back to Table of Contents
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair
Doc Number Version Issued Review Date Area Responsible PageCHHS17/209 1 05/09/2017 01/09/2019 Medicine 6 of 6
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
