Shaky foundations: The evidence base supporting dietetic interventions in chronic kidney disease

摘要

Background: Evidence-based guidelines for chronic kidney disease (CKD) focus on single nutrients and malnutrition, with no recommendations for what and how interventions are delivered. Aim: To review the efficacy and implementation of nutrition assessment and interventions delivered to patients with CKD. Methods: Systematic review up to November 2019 of CENTRAL, CINAHL, EMBASE, MEDLINE and Psy-cINFO, of randomised controlled trials (RCTs), quasi-RCTs and non-randomised trials with >6 months follow-up; any stage of CKD, designed/delivered by dietitians; in any setting. Intentional weight loss and single nutrient studies were excluded. Titles and abstracts were screened and data extracted, including quality assessment using the Cochrane "Risk of Bias" tool. Results: 12 trials involving 9 different intervention types and 1906 participants were identified; 5 in stages 3-4 CKD, 3 in haemodialysis, and 4 in kidney transplant recipients. Risk of bias was generally "unclear"; with 'high' risk of performance bias due to lack of blinding. Nutrition interventions post-transplant with a Mediterranean diet or high n-3 PUFA intake improved blood lipids. In haemodialysis, interventions addressing nutrition-related barriers increased protein and energy intake. High fruit and vegetable intake, and a multidisciplinary group-based program plus usual care, both slowed eGFR decline in stages 3-4 CKD, compared to usual care. Intensive interventions showed no benefit over standard dietetic care. There were no studies of timing/frequency of nutrition assessment, or addressing malnutrition; nor any in peritoneal dialysis or supportive care. Conclusions: Few studies exist providing evidence to support service development in this patient population.