Evidence-Based Care Summary 1

Evidence-Based Care Summary

Hannah Bodenhamer

School of Kinesiology and Nutrition, University of Southern Mississippi

NFS 780: Advanced Practice in Nutrition and Food Systems

Professor Kingston, MS, RD

October 20, 2021

Evidence-Based Care Summary 2

Evidence-Based Practice Worksheet

Intern Name

Hannah Bodenhamer

Disease State

Chronic Kidney Disease (Renal)

100-word summary of your patient’s medical diagnosis, care, prognosis, and nutrition needs. USM
students MUST submit a copy of their actual chart note and NCP form for this patient in NFS 567L.

The patient was admitted to the facility with stage 5 chronic kidney disease (CDK) and end-stage renal
disease (ESRD). The patient is currently receiving maintenance hemodialysis (MHD) at an off-site
dialysis center three times per week. An admission assessment was ordered and the Registered Dietitian
Nutritionist (RDN) recommended a 2,850-3,325 kcal diet with 114 grams of protein and a 2,000 cc
fluid restriction. The RDN ordered a renal diet, with regular texture, and thin liquids for this patient.
The renal diet includes 79 grams of protein so the RDN discussed administering a Pro-Stat protein
supplement to the patient for increased dietary protein.

350-word abstract of a peer-reviewed research article on the Nutrition-Related care of this type of
disease/condition. The following must be included: reference (not included in the word count) purpose,
methods, results (including actual data & p-values, as appropriate, and conclusions. A copy of the
article also MUST be attached to the assignment in Canvas.

Saglimbene, V. M., Wong, G., Ruospo, M., Palmer, S. C., Garcia-Larsen, V., Natale, P., Teixeira-Pinto,
A., Campbell, K. L., Carrero, J. J., Stenvinkel, P., Gargano, L., Murgo, A. M., Johnson, D. W.,
Tonelli, M., Gelfman, R., Celia, E., Ecder, T., Bernat, A. G., Del Castillo, D., Timofte, D., …
Strippoli, G. (2019). Fruit and Vegetable Intake and Mortality in Adults undergoing
Maintenance Hemodialysis. Clinical journal of the American Society of Nephrology : CJASN,
14(2), 250–260. https://doi.org/10.2215/CJN.08580718

The purpose of this study is to determine the impact of fruit and vegetable intake on MHD-related
mortality. Fruit and vegetable intake is typically associated with lower all-cause and
cardiovascular-related mortality but is typically not recommended in high amounts to patients with
CKD due to the risk of hyperkalemia. However, the relationship between fruit and vegetable intake and
mortality amongst adults with MHD treatment has minimal research. 83% (8,078) of the original
multinational group of 9,757 adults on MHD who participated in this study had analyzable data from
their food frequency questionnaires (FFQ). An adjusted cox regression analysis was conducted to
assess the relationship between different tertiles of fruit and vegetable intake with cardiovascular,
noncardiovascular, and all-cause mortality. A follow-up was conducted after approximately three years
from the initial FFQ (median 2.7 years) and found that 26% of study participants had died. The findings
of fruit and vegetable intake were divided into tertiles, in which the lowest tertile consumed 0-5.5
servings per week, the me middle tertile consumed 5.6-10 servings per week, and the highest tertile
Evidence-Based Care Summary 3

consumed greater than 10 servings per week. The adjusted hazard ratios of the middle and highest
tertiles compared to the lowest tertile were .95 (95% CI) and .84 (95% CI) for cardiovascular-related
mortality (p=.14), .88 (95% CI) .77 (95% CI) for noncardiovascular-related mortality (p=.01), and .9
(95% CI) and .8 (95% CI) for all-cause mortality (p=.002), respectively. Compared to the tertile with
lowest fruit and vegetable servings per week (median 2), the middle tertile (median 8) and highest
tertile (median 17) were associated with lower all-cause and noncardiovascular-related mortality.
Evidence for a relationship between cardiovascular-related mortality and fruit and vegetable intake was
weak. This study found that increasing fruits and vegetable intake to 17 servings per week, as compared
to 2 servings per week, resulted in a 20% lower risk of mortality. Fruit and vegetable intake in patient
populations receiving MHD was found to be very low; however, those with higher intakes had better
outcomes. Increasing fruit and vegetable intake may create positive patient outcomes for those
receiving MHD.

100-word summary of the EAL, Cochrane, or ASPEN evidence summary of the nutrition-related
guidelines

According to the EAL (2020), fruits and vegetables are recommended to individuals with CKD stages
1-4 but there is no recommendation for individuals with CKD stage 5D. Additionally, a protein intake
of 1.0-1.2g/kg is recommended for those with CDK stage 5D, with no support favoring a particular
source of protein. The suggested energy intake of 25-35kcal/kg is recommended depending on a variety
of factors including weight, illness severity, and age. Phosphorus, potassium, and calcium should be
adjusted to maintain normal serum levels and sodium should be limited to 2.3 grams/day. Patients
receiving MDH should receive medical nutrition therapy to optimize nutrition status and minimize
health risks.

Summary of the strengths and limitations of the research article and the rating of the evidence provided
in the summary.

The effect of fruit and vegetable intake on mortality with patients receiving MHD had not been
investigated before this research; therefore, the area of study is a strength. Because this is the first study
of this kind, this research creates opprotunity for further investigation.There are several limitations to
this research. First, the serving size and frequency data for fruit and vegetable intake was self-reported
which leads to the possibility of measurement bias, recall bias, misclassification of exposure, and false
data. Additionally, the researchers did not explore other factors that may explain the reported mortality
outcomes as biochemical data was not available. Finally, the research excluded participants who had
incomplete food frequence questionnaires, which may have created some selection bias in the data.

The EAL evidence for fruits and vegetables intake for CKD stages 1-4 is weak and conditional. The
evidence supporting a 1.0-1.2 g/kg daily protein intake is fair and conditional and evidence for protein
type is strong and imperative. The recommendations on energy intake is fair and imperative. The
electrolyte evidence is strong imperative for phosphorus, consensus conditional for potassium and
calcium, and fair imperative for sodium. The recommendations for MNT are fair imperative.
Evidence-Based Care Summary 4

150-200-word summary of how the research and evidence can be used in clinical practice

Further research is warranted in order to confirm the evidence reported in this study and to form a
conclusive recommendation. Though the biases and inaccuracies stated in the report are not definite, it
calls additional studies to confirm results. The information provided in the research indicates that
higher intakes of fruits and vegetables may reduce mortality risk in those receiving MHD. This
contradicts common medical advice stating that individuals with CKD stage 5D should avoid fruits and
vegetables due to the risk for hyperkalemia. The National Kidney Foundation hosts a website with fruit
and vegetable recommendations to include and exclude in one’s diet to mitigate risk for hyperkalemia
(2021). Overall, patients receiving MHD should not be discouraged from fruit and vegetable intake as
this food group is widely recommended for optimal health and wellness. Current studies suggest
increasing fruit and vegetable intake with moderation the type of produce consumed to achieve positive
patient outcomes for those receiving MHD. RDNs should take these outcomes into consideration
during nutrition assessments for patients with CKD stage 5D, but should still use clinical judgement to
make final recommendations.
Evidence-Based Care Summary 5

References

Chronic kidney disease. EAL. (n.d.). Retrieved October 27, 2021, from
https://www.andeal.org/topic.cfm?menu=5303&cat=5557.

Dietary guidelines for adults starting on Hemodialysis. National Kidney Foundation. (2021, June 1).
Retrieved October 29, 2021, from https://www.kidney.org/atoz/content/dietary_hemodialysis.

Saglimbene, V. M., Wong, G., Ruospo, M., Palmer, S. C., Garcia-Larsen, V., Natale, P., Teixeira-Pinto, A.,
Campbell, K. L., Carrero, J. J., Stenvinkel, P., Gargano, L., Murgo, A. M., Johnson, D. W.,
Tonelli, M., Gelfman, R., Celia, E., Ecder, T., Bernat, A. G., Del Castillo, D., Timofte, D., …
Strippoli, G. (2019). Fruit and Vegetable Intake and Mortality in Adults undergoing Maintenance
Hemodialysis. Clinical journal of the American Society of Nephrology : CJASN, 14(2), 250–260.
https://doi.org/10.2215/CJN.08580718