Presente e futuro della
terapia nutrizionale della
CKD, razionale costi
benefici
Dr. G. Quintaliani
Scuola di Specializzaz...
La nutrizione come causa di malattia
• WHO > Programmes and projects >
Nutrition
• Main content
• printable version
• Nutr...
La nutrizione come cura
• "diet therapy"[Subheading]
A low-nitrogen diet with protein of high biological value for severe chronic uremia. Giovannetti S, Maggiore Q: Lancet I:1...
Why then is dietary counseling used irregularly ?
We believe there are three major reasons:
Why then is dietary counseling used irregularly ?
We believe there are three major reasons:
(1) the initial MDRD report co...
Studi randomizzati e controllati
condotti in doppio cieco
Ricerca “in-vitro” e su modelli cellulari
Ricerca su modelli ani...
REGIONI % VOLUME REGIONI
SICILIA 23,90%
UMBRIA + LAZIO 18,20%
CAMPANIA 16,10%
MOLISE + PUGLIA + BASILICATA 8,60%
TOSCANA 8...
Studi randomizzati e controllati
condotti in doppio cieco
Ricerca “in-vitro” e su modelli cellulari
Ricerca su modelli ani...
CONCLUSION: Dietary protein restriction effectively slows
the progression of both diabetic and nondiabetic renal diseases
...
Fig. 1. Reduction in the odds of renal death in seven prospective
randomized studies of protein restriction in chronic ren...
Terapia dietetica
1.Antihypertensive agents for dialysis patients (Cochrane Protocol).
2.Antimicrobial agents for preventing peritonitis in ...
A Randomized, Double-Blind, Placebo-Controlled Study to Assess the Efficacy
and Safety of Cinacalcet HCl in Participants W...
• large prospective randomized study of sevelamer versus
calcium binders was undertaken in an effort to show
reduced morta...
• The nephrologist should know that prescribing an aluminum-or calcium-free product for controlling
hyperphosphatemia in d...
Che cosa significa Farmaco Efficace
Efficacia terapeutica
Va intesa non solo come capacità di
correggere parametri biochim...
Rosuvastatina in dialisi studio poe vs doe
• Results After 3 months, the mean reduction in low-density lipoprotein (LDL)
c...
Incidenza
153 / pmp
8721
Prevalenza
734 / pmp
41.000
SIN-RIDT
2009 Report Referring to the
Calendar Year 2007
Costi della CKD
Costi della dialisi
Costo annuale per la dialisi extracorporea di circa US $
51,252 per la dialisi al centro; $ 42,057 CAL...
Il CENSIS suggerisce in Italia un costo della Emodialisi
in acetato o in bicarbonato (ospedaliera) di
63.885.457 Milioni d...
Costi dialisi CENSIS 2009
metodica costi indiretti costi diretti sociali tot settimana tot anno
HD 51,39 166,42 98,73 949,...
Dieta Ipoproteica e Sicurezza in Anziani CKD
Analisi primaria
DODE-study
RCT x sopravvivenza
GFR = 5 - 7 ml/min
Dieta 0,3 ...
Blood pressure and time to ESRD
0
10
20
30
40
50
60
Time ( years )
BaselineGFR(ml/min)
0 2 4 6 8 10 12 14 16
MDRD Study A
...
Diet and time to ESRD
0
10
20
30
40
50
60
Time ( years )
BaselineGFR38.6ml/min)
0 2 4 6 8 10 12 14 16
MDRD Study A
Locatel...
Caratteristiche dell’MDRD Study I
• È stato ipotizzato che un paziente nefropatico inizi la
dieta ipoproteica con una GFR ...
Dieta per insufficienza renale cronica grave
(con utilizzo di prodotti aproteici)
con un apporto calorico di 2000 Kcal/4 -...
COSTI
7 anni di dieta ipoproteica*
€ 15.000
* Valori attualizzati al 3%
BENEFICI
2 anni di
dialisi*
€ 98.000
EFFETTI
Dilaz...
Diabete hb glicosilata
• Conclusions
• As compared with standard therapy, the use of
intensive therapy to target normal gl...
Results: Prevalence of medication noncompliance was
36.9% (95% confidence interval [95% CI], 28.6%-45.8%).
• Patient education programs have been shown to be an effective
adjunct to other methods of phosphate control.
• Sadly, ra...
La dietista e i cambiamenti delle
abitudini alimentari
La dieta nella IRC
Gli alimenti ipoproteici e il loro uso
Dietista on line
• Conclusions: This study documented the frequency of dietitians performing job functions
related to renal dietetics. The ...
multidisciplinarità
• Infermieri
IRC
• Dietisti
• Nefrologi
integrated course involving
individual lectures on renal health, delivered by the
case-management nurse, according to the ...
Why then is dietary counseling used irregularly ?
We believe there are four major reasons:
(1) the initial MDRD report con...
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici
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giornate nefrologiche pisane: Quintaliani Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici

  1. 1. Presente e futuro della terapia nutrizionale della CKD, razionale costi benefici Dr. G. Quintaliani Scuola di Specializzazione in Nefrologia - Perugia
  2. 2. La nutrizione come causa di malattia • WHO > Programmes and projects > Nutrition • Main content • printable version • Nutrition for Health and Development
  3. 3. La nutrizione come cura • "diet therapy"[Subheading]
  4. 4. A low-nitrogen diet with protein of high biological value for severe chronic uremia. Giovannetti S, Maggiore Q: Lancet I:1100:1004,1964
  5. 5. Why then is dietary counseling used irregularly ? We believe there are three major reasons:
  6. 6. Why then is dietary counseling used irregularly ? We believe there are three major reasons: (1) the initial MDRD report concluded that a low- protein diet did not significantly slow progression of CKI in nondiabetic patients (2) designing these diets requires a skilled dietitian, and this can be costly; (3) changing the diet is difficult for some patients;
  7. 7. Studi randomizzati e controllati condotti in doppio cieco Ricerca “in-vitro” e su modelli cellulari Ricerca su modelli animali Editoriali, rassegne, ed opinioni di “esperti” Casi clinici Serie di casi e Studi trasversali Studi caso-controllo Studi di coorte RCT DB RCT Studi randomizzati e controllati Meta-analisi ClinicalTrials Non tutto quello che trovate vi serve….
  8. 8. REGIONI % VOLUME REGIONI SICILIA 23,90% UMBRIA + LAZIO 18,20% CAMPANIA 16,10% MOLISE + PUGLIA + BASILICATA 8,60% TOSCANA 8,60% CALABRIA 5,10% LIGURIA 3,90% VALLE D'AOSTA + PIEMONTE 3,50% LOMBARDIA 2,90% EMILIA ROMAGNA 2,60% MARCHE + ABRUZZO 2,40% SARDEGNA 2,00% FRIULI VENEZIA GIULIA 1,40% VENETO + TRENTINO ALTO ADIGE 0,70% Il mercato aproteico
  9. 9. Studi randomizzati e controllati condotti in doppio cieco Ricerca “in-vitro” e su modelli cellulari Ricerca su modelli animali Editoriali, rassegne, ed opinioni di “esperti” Casi clinici Serie di casi e Studi trasversali Studi caso-controllo Studi di coorte RCT DB RCT Studi randomizzati e controllati Meta-analisi ClinicalTrials Non tutto quello che trovate vi serve….
  10. 10. CONCLUSION: Dietary protein restriction effectively slows the progression of both diabetic and nondiabetic renal diseases Annals of Internal Medicine 1996Volume 124 Issue 7 Pages 627- 632
  11. 11. Fig. 1. Reduction in the odds of renal death in seven prospective randomized studies of protein restriction in chronic renal insufficiency. A square denotes the odds ratio (treatment/control) for each trial and the diamond for the overall results. 95% CIs are represented by the horizontal lines. Overall ‘common’ odds ratio=0.61 (95% CI: 0.46, 0.83), P=0.006. Test for heterogeneity between studies: 2=4.84; degrees of freedom=6, P=0.56. Low protein diets delay end-stage renal disease in non-diabetic adults with chronic renal failure Denis Fouque,1,2, Ping Wang2,3, Maurice Laville1,2 and Jean-Pierre Boissel2 Nephrol Dial Transplant (2000) 15: 1986-1992
  12. 12. Terapia dietetica
  13. 13. 1.Antihypertensive agents for dialysis patients (Cochrane Protocol). 2.Antimicrobial agents for preventing peritonitis in peritoneal dialysis patientsFull Text 3.Bicarbonate versus lactate solutions for acute peritoneal dialysis (Cochrane Protocol). 4.Biocompatible dialysis fluids for peritoneal dialysis (Cochrane Protocol). 5.Biocompatible hemodialysis membranes for acute renal failureFull Text Available 6.Calcimimetics for secondary hyperparathyroidism in chronic kidney disease patientsFull 7.Calcium dialysate concentration for peritoneal dialysis (Cochrane Protocol). 8.Catheter type, placement and insertion techniques for preventing peritonitis in peritoneal dialysis patientsFull Text Available (Cochrane Review). 9.Cellulose, modified cellulose and synthetic membranes in the haemodialysis of patients with end-stage renal diseaseFull Text Available (Cochrane Review). 10.Continuous ambulatory peritoneal dialysis (CAPD) versus hospital or home haemodialysis for end-stage renal disease in adultsFull Text Available (Cochrane 11.Continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis for end-stage renal diseaseFull Text Available (Cochrane 12.Correction of chronic metabolic acidosis for chronic kidney disease patientsFull Text Available (Cochrane Review). 13.Cyclosporin versus tacrolimus for liver transplanted patientsFull Text Available (Cochrane 14.Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage renal diseaseFull Text Available (Cochrane 15.Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal functionFull Text Available (Cochrane Review). 16.Emergency interventions for hyperkalaemiaFull Text Available (Cochrane Review). 17.Frequency of administration of recombinant human erythropoietin for anaemia of end-stage renal disease in dialysis patientsFull Text Available (Cochrane 18.Growth hormone for children with chronic kidney diseaseFull Text Available (Cochrane 19.Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney diseaseFull 20.Haemoglobin and haematocrit targets for the anaemia of chronic kidney diseaseFull Text 21.HMG CoA reductase inhibitors (statins) for dialysis patientsFull Text Available (Cochrane. 22.HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysisFull Text Available (Cochrane Review). 23.Immunosuppressive treatment for focal segmental glomerulosclerosis in adultsFull Text Available 24.Immunosuppressive treatment for idiopathic membranous nephropathy in adults with nephrotic syndromeFull Text Available (Cochrane Review). 24.Intermittent versus continuous renal replacement therapy for acute renal failure in adultsFull Text Available (Cochrane Review). 25.Interventions for dialysis patients with hepatitis C virus (HCV) infection (Cochrane 26.Interventions for dialysis-associated restless legs syndrome (Cochrane Protocol). 27.Interventions for erythropoietin-resistant anaemia in dialysis patients (Cochrane Protocol). 28.Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura 29.Interventions for lowering plasma homocysteine levels in dialysis patients (Cochrane 30.Interventions for non-oliguric hyperkalaemia in preterm neonatesFull Text Available 31.Interventions for preventing bone disease in kidney transplant recipientsFull Text Available 32.Low protein diets for chronic kidney disease in non diabetic adultsFull Text Available 33.Medical adjuvant treatment to increase patency of arteriovenous fistulae and graftsFull Text 34.Physical measures for treating depression in dialysis patientsFull Text Available (Cochrane 35.Pre and peri-operative erythropoeitin for reducing allogeneic blood transfusions in colorectal cancer surgery.Full Text Available (Cochrane Review). 36.Protein restriction for children with chronic kidney diseaseFull Text Available (Cochrane 37.Psychosocial interventions for depression in dialysis patientsFull Text Available (Cochrane 38.Recombinant human erythropoietin for chronic renal failure anaemia in pre-dialysis patientsFull 39.Tidal peritoneal dialysis for acute renal failure (Cochrane . 40.Treatment for peritoneal dialysis-associated peritonitisFull Text Available (Cochrane 40.Vitamin D compounds for people with chronic kidney disease not requiring dialysisFull 41.Vitamin D compounds for people with chronic kidney disease requiring dialysis
  14. 14. A Randomized, Double-Blind, Placebo-Controlled Study to Assess the Efficacy and Safety of Cinacalcet HCl in Participants With CKD Not Receiving Dialysis Volume 53, Issue 2, Pages 197-207 (February 2009) • Conclusions These data show that cinacalcet treatment in patients with CKD not receiving dialysis can decrease plasma iPTH levels, but with frequent ((albeit generally asymptomatic) serum calcium levels less than 8.4 mg/dL and increases in serum phosphorus levels • Limitations The study was not designed to assess the effects of cinacalcet on vascular calcification, bone histomorphometric parameters, or other clinical outcomes. It is not known whether the observed differences in changes in iPTH levels are clinically more important than observed differences in changes in serum calcium or phosphorus levels or dosages of vitamin D sterols and phosphate binders. American Journal of Kidney Diseases
  15. 15. • large prospective randomized study of sevelamer versus calcium binders was undertaken in an effort to show reduced mortality (the DCOR study), produced a negative result, • However, a subsequent post hoc analysis of subgroups suggested a survival advantage for patients aged over 65 years, but the statistical and clinical validity of this finding remains controversial. • More recently, a secondary analysis found that treatment with sevelamer versus calcium-based binders did not affect overall mortality (primary outcome), cause- specific mortality, morbidity, or first or cause-specific hospitalization (secondary outcomes),
  16. 16. • The nephrologist should know that prescribing an aluminum-or calcium-free product for controlling hyperphosphatemia in dialysis (sevelamer at the time of writing these lines) may suppose increasing the costs by 209 euros per month, on average. Considering that each year 5,000 patients start on dialysis, of which 50% have a phosphorus level > 5.5 mg/dL, the cost just for these incident uncontrolled patients would be higher than € 6 million per year had they been treated with calcium- free chelating agents. • . Taking all this information together, and applying information we have available, the invoicing of the only aluminum- and calciumfree phosphorus-chelating product available in our country is about € 20 million per year. And this expenditure seems not to be related with a decreased hospitalization rate, cardiovascular events, or morbimortality.
  17. 17. Che cosa significa Farmaco Efficace Efficacia terapeutica Va intesa non solo come capacità di correggere parametri biochimici o funzionali alterati (efficacia clinica), ma soprattutto di migliorare la qualità della vita o allungare la sua durata (efficacia epidemiologica). In altri termini l’efficacia va misurata sul paziente, non (o non solo) sulla malattia
  18. 18. Rosuvastatina in dialisi studio poe vs doe • Results After 3 months, the mean reduction in low-density lipoprotein (LDL) cholesterol levels was 43% in patients receiving rosuvastatin, from a mean baseline level of 100 mg per deciliter. • Rosuvastatin had no effect on individual components of the primary end point. There was also no significant effect on all-cause mortality (13.5 vs. 14.0 events per 100 patient-years; hazard ratio, 0.96; 95% CI, 0.86 to 1.07; P=0.51). • Conclusions In patients undergoing hemodialysis, the initiation of treatment with rosuvastatin lowered the LDL cholesterol level but had no significant effect on the composite primary end point of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. (ClinicalTrials.gov number, NCT00240331 [ClinicalTrials.gov] .)
  19. 19. Incidenza 153 / pmp 8721 Prevalenza 734 / pmp 41.000 SIN-RIDT 2009 Report Referring to the Calendar Year 2007
  20. 20. Costi della CKD
  21. 21. Costi della dialisi Costo annuale per la dialisi extracorporea di circa US $ 51,252 per la dialisi al centro; $ 42,057 CAL/ CAD e., self dialisi $ 29,961 e peritoneale. $ 26,959. American Journal of Kidney Diseases, Vol 40, No 3 (September), 2002: pp 611-622
  22. 22. Il CENSIS suggerisce in Italia un costo della Emodialisi in acetato o in bicarbonato (ospedaliera) di 63.885.457 Milioni di lire equivalenti a € 33.146,61 • In particolare l'indagine del Censis sui costi e l'efficacia dei principali trattamenti dialitici rivela che il costo totale, come somma di costo economico e costo sociale, facente capo ai circa 39 mila pazienti presenti in Italia risulta pari a quasi 2 mila e settecento miliardi di lire, di cui circa 700 miliardi rappresentano il costo sociale (pari a oltre un quarto del costo totale) in gran parte ad esclusivo carico delle famiglie. http://www.censis.it/277/372/4974/5112/5148/5149/content.ASP Anno 2004
  23. 23. Costi dialisi CENSIS 2009 metodica costi indiretti costi diretti sociali tot settimana tot anno HD 51,39 166,42 98,73 949,62 € 49.380,24 HDf 51,73 217,14 98,73 1102,8 € 57.345,60 APD 15,87 69,86 98,73 553,38 € 28.775,76 CAPD 14,81 55,3 98,73 506,52 € 26.339,04 http://www.censis.it/277/372/6697/6739/cover.asp
  24. 24. Dieta Ipoproteica e Sicurezza in Anziani CKD Analisi primaria DODE-study RCT x sopravvivenza GFR = 5 - 7 ml/min Dieta 0,3 g/kg vs Dialisi Pts>70 anni Brunori G., Am J Kidney Disease 2007 Analisi ITT aggiustata : HR per non inferiorità, p < 0.01 Reg Log, OR dieta = 2.21 (1.02-4.83); p = 0.04 Tempo mediano in dieta senza dialisi : ឳ 1 anno
  25. 25. Blood pressure and time to ESRD 0 10 20 30 40 50 60 Time ( years ) BaselineGFR(ml/min) 0 2 4 6 8 10 12 14 16 MDRD Study A Locatelli F and Del Vecchio L Nephrol Dial Transplant 1999;14:1360-4 Target blood pressure - 3.5 ml / min / year MAP 92 mmHg MAP 107 mmHg - 4.1 ml / min / year ' Time 1.24 years
  26. 26. Diet and time to ESRD 0 10 20 30 40 50 60 Time ( years ) BaselineGFR38.6ml/min) 0 2 4 6 8 10 12 14 16 MDRD Study A Locatelli F and Del Vecchio L Nephrol Dial Transplant 1999;14:1360-4 - 3.6 ml / min / year Low protein diet 9,3 years Usual diet 8,3 years - 4.03 ml / min / year ' Time 1. 0 years
  27. 27. Caratteristiche dell’MDRD Study I • È stato ipotizzato che un paziente nefropatico inizi la dieta ipoproteica con una GFR pari a 25 ml/min/1,73 m2.* e inizi la dialisi quando raggiunge una GFR di 5 ml/min/1,73 m2.° • Applicando il declino medio della GFR ottenuto dal MDRD Study I un soggetto trattato con una dieta a basso contenuto di proteine (low protein diet) entra in dialisi dopo circa 7 anni; un soggetto che segue una “usual protein diet” dopo circa 5 anni. * Livelli di GFR in cui secondo la comune pratica medica sarebbe opportuno iniziare una dieta ipoproteica Ꮦ Livelli di GFR in cui secondo la comune pratica medica sarebbe opportuno iniziare il trattamento di dialisi Centro di Farmacoeconomia Università degli Studi di Milano
  28. 28. Dieta per insufficienza renale cronica grave (con utilizzo di prodotti aproteici) con un apporto calorico di 2000 Kcal/4 - proteine 40 gr/die * Prezzo €uro/ Kg Ꮦ Tariffa SSN Centro di Farmacoeconomia Università degli Studi di Milano 123,9620,66 (€)* Visita specialistica 2023,89Costo totale 1899,93DIETA (prodotti) Costo annuale (€)* Costi Alimentazione Ipoproteica/Y
  29. 29. COSTI 7 anni di dieta ipoproteica* € 15.000 * Valori attualizzati al 3% BENEFICI 2 anni di dialisi* € 98.000 EFFETTI Dilazione di 2 anni ingresso in dialisi L’impiego di una dieta ipoproteica per 7 anni nel trattamento dell’insufficienza renale cronica dilaziona l’ingresso in dialisi di 2 anni con un BENEFICIO NETTO di 98.000 – 15.000 = 82.000 € per paziente Centro di Farmacoeconomia Università degli Studi di Milano Risultati
  30. 30. Diabete hb glicosilata • Conclusions • As compared with standard therapy, the use of intensive therapy to target normal glycated hemoglobin levels for 3.5 years increased mortality and did not significantly reduce major cardiovascular events. These findings identify a previously unrecognized harm of intensive glucose lowering in high-risk patients with type 2 diabetes. (ClinicalTrials.gov number, NCT00000620.)
  31. 31. Results: Prevalence of medication noncompliance was 36.9% (95% confidence interval [95% CI], 28.6%-45.8%).
  32. 32. • Patient education programs have been shown to be an effective adjunct to other methods of phosphate control. • Sadly, randomized prospective outcome studies of the benefits of reducing serum phosphate have yet to be undertaken, and the achievement of targets set by opinion-based guidelines seem to have become accepted 'outcomes' in themselves. It is to be hoped that the eagerly awaited KDIGO CKD-MD guidelines will acknowledge the lack of good quality data, and stimulate high quality RCT-based research, rather than a plethora of publications that seek only to measure the achievement of biochemical targets. If so, perhaps we can really begin to understand first the role of serum phosphate, and second, that of oral phosphate binders, in the management of patients with CKD.
  33. 33. La dietista e i cambiamenti delle abitudini alimentari
  34. 34. La dieta nella IRC Gli alimenti ipoproteici e il loro uso
  35. 35. Dietista on line
  36. 36. • Conclusions: This study documented the frequency of dietitians performing job functions related to renal dietetics. The results of this study document the variability in the role of renal dietitian, and suggest differing levels of practice within renal dietetics. • 2009 by the National Kidney Foundation, • In daily practice, dietetics practitioners can consistently demonstrate competency and value as providers of safe, effective, and optimal nephrology care. These standards also serve as a professional resource for self-evaluation and professional development for RDs specializing in nephrology care. As a quality initiative of the ADA RPG and the NKF CRN, the standards themselves are an application of continuous quality improvement concepts. • 2009 by the National Kidney Foundation,
  37. 37. multidisciplinarità • Infermieri IRC • Dietisti • Nefrologi
  38. 38. integrated course involving individual lectures on renal health, delivered by the case-management nurse, according to the guidelines in a standardized instruction booklet. The lectures focused on nutrition, lifestyle, nephrotoxin avoidance, dietary principles and pharmacological regimens. Further, the case-management nurse contacted the patients to ensure timely follow-up. All patients received dietary counselling from a dietitian. Additionally, the case-management nurse often contacted the participants via telephone to encourage them to inform their nephrologists of their symptoms and to reinforce the importance of medical visits.
  39. 39. Why then is dietary counseling used irregularly ? We believe there are four major reasons: (1) the initial MDRD report concluded that a low- protein diet did not significantly slow progression of CKI in nondiabetic patients (2) designing these diets requires a skilled dietitian, and this can be costly; (3) changing the diet is difficult for some patients; We believe none of these are sufficiently persuasive to avoid using this time-tested therapy to prevent complications of CKI

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