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A Novel Clinical Tool for the Management of Taste Changes in Patients With
Chronic Kidney Disease: The Chronic Kidney Disease Taste Plate

Article  in  Journal of Renal Nutrition · August 2021

DOI: 10.1053/j.jrn.2021.06.010

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PRACTICAL ASPECTS
A Novel Clinical Tool for the Management of
Taste Changes in Patients With Chronic
Kidney Disease: The Chronic Kidney
Disease Taste Plate
Frank Brennan, MBBS, FRACP, FAChPM, LLB,* Jessica Dawson, BHSc(Nutr), MNutDiet,† and
Mark A. Brown, MBBS, FRACP, MD*,†,‡
Taste alteration is a common, but poorly understood, symptom in end-stage kidney disease. The pathophysiology of taste alteration is
complex; to date, management has been largely empirical. As our understanding of pathophysiology grows so does the evidence base
for its management. This article introduces a clinical tool—the CKD Taste Plate—to assist clinicians in directing management to the un-
derlying pathophysiology of taste alterations in chronic kidney disease.
Ó 2021 by the National Kidney Foundation, Inc. All rights reserved
Introduction and Purpose
T ASTE ALTERATION IS a common symptom in
chronic kidney disease (CKD), especially end-stage
kidney disease (ESKD).1 The prevalence of taste changes
is approximately 38% in ESKD, with patients reporting
slight to overwhelming alterations in taste.2 Additionally,
the presence of taste changes has been associated with the
presence and increasing severity of other upper gastrointes-
tinal symptoms.2 The physiology of human taste is complex
and the understanding of the pathophysiology of taste
changes in ESKD remains incomplete.3 Historically, the
management of taste changes in CKD has been largely
empirical and based on literature from oncology. As the un-
derstanding of taste pathophysiology develops, the ability of
linking specific management strategies to that knowledge
emerges. In this article, we introduce a new clinical tool,
the CKD Taste Plate (hereafter referred to as ‘‘the Plate’’),
to aid clinicians in managing common taste alterations
experienced by patients with CKD. We describe the devel-
opment of the Plate, the science that underlies it, and its po-
tential utility in clinical practice.
*
Department of Renal Medicine, St George Hospital, Sydney, Australia.
†
Department of Nutrition and Dietetics, St George Hospital, Sydney,
Australia.
‡
St George and Sutherland Clinical School, University of New South Wales,
Sydney, Australia.
Address correspondence to Dr Frank Brennan, Department of Renal Medicine,
St George Hospital, 50 Montgomery Street, Kogarah, NSW 2217, Australia.
E-mail: fpbrennan@ozemail.com.au
Ó 2021 by the National Kidney Foundation, Inc. All rights reserved
1051-2276/$36.00
https://doi.org/10.1053/j.jrn.2021.06.010
Journal of Renal Nutrition, Vol -, No - (-), 2021: pp 1-6
Evidence Informing the Development of the
Clinical Tool
The science and evidence behind the Plate is based on
the normal physiology of human taste, the pathophysiology
of taste changes in CKD, and a strategic response based on
that pathophysiology. This information has been previously
published.3 For the convenience of the reader, we recom-
mend they read this paper with that publication. A brief
summary of the physiology of taste is outlined in Table 1
and a brief review of the pathophysiology of taste changes
in CKD is summarized in Table 2. In essence, the evidence
shows a significant change in salivary pH and electrolyte
composition in patients with CKD. It is postulated that
these changes affect the taste cells on taste buds.
It is clear that ‘‘taste alteration’’ is an umbrella term and
that the clinical manifestation of that alteration is heteroge-
neous. According to international literature in CKD pa-
tients and our clinical experience, descriptors could
predominantly be categorized as follows: absent or bland
taste, salty, metallic and bitter tastes.2,4 Each description
will likely have a discrete pathophysiology and therefore
management needs to reflect those subtle differences in
etiology.
Objective
The objective of the Plate was to create a clinical aid that
is simple, visually appealing, uncluttered, expressed in clear
language, and could be used by any health professional. In
the development of the Plate, we recognized that linking
management to pathophysiology was vital. The Plate illus-
trates two important aspects when assessing taste changes
and recommending interventions:
1. The specific taste alteration described by the patient
(absent taste, bland, bitter, salty, metallic).
1
2 BRENNAN ET AL
Table 1. A Brief Summary of the Normal Physiology of
Human Taste3
 There are 5 separate tastes: sweet, sour, bitter, salty,
umami (savory)
 On the tongue there are numerous taste buds
 On each taste bud are groups of chemoreceptive taste
receptor cells: taste cells I, II, and III. Type I cells detect salt
taste; type II cells detect sweet, bitter, and umami tastes;
and type III cells detect sour and, in certain circumstances,
salt taste
 The sensitivity of taste buds to individual tastes varies and
has a genetic component
 The taste cells cross-talk and communicate with each
other
 In addition to taste, there are sensations of chemosensis
(the the sense of texture and temperature) and flavor (the
combination of taste and smell)
2. A recommended management strategy based on the
current knowledge of pathophysiology.
The Development of the Chronic Kidney
Disease Taste Plate
The sequence of development of the CKD Taste Plate
was:
1. A review of the basic physiology of normal taste and
the pathophysiological changes to normal taste asso-
ciated with CKD.3
2. The creation of the CKD Taste Plate by the first
author of this manuscript.
3. Once the Plate was designed there was a consultation
process. This comprised asking the following to re-
view and comment on the Plate: a senior Renal Die-
titian (author 2 on the list of authors of this
manuscript), two Nephrologists (one of whom is
author 3 of this manuscript; the second Nephrologist
is also trained as a Palliative Care Physician), and two
senior Renal Supportive Care Nurses.
4. Comments were fed back to the first author who
then refined the design of the Plate accordingly.
5. A second round of consultation occurred until there
was consensus agreement.
The Chronic Kidney Disease Taste Plate
The CKD Taste Plate (Fig. 1) contains two domains, an
inner circle and an outer circle.
Inner Circle
The inner circle represents the most common descriptors
by patients when self-reporting taste alteration.
Outer Circle
The second step is to consult that part of the outer circle
adjacent to the nominated section of the inner circle.
The outer circle contains the recommended interventions
based on the underlying pathophysiology of the specific
taste alteration.
Two case studies highlighting the use of the Plate in clin-
ical care are outlined in Table 3.
Utility in Clinical Practice
In a clinical setting, there are a series of logical steps to
follow from the screening for taste changes through to
management. The first important step is screening. Taste
changes may be subtle until severe and, even then, may
be a source of silent suffering for a patient. Patients may
not volunteer this symptom. Equally, taste alteration may
be never the subject of a direct medical or nursing enquiry.
Marquez-Herrera et al.4 developed and validated a Taste
Perception Test for dialysis patients who identified their
perception of the classic 5 tastes. In terms of the subjective
reporting of taste alteration (absent taste, bitter, salty, etc.),
Manley5 incorporated that enquiry into a broader instru-
ment that included upper gastrointestinal symptoms.
Over several years, our Renal Supportive Care Clinic has
added the symptom of abnormal taste changes to our
routine validated renal symptom instrument (the IPOS-
Renal) given to every patient at every clinic visit. If the pa-
tient answers in the affirmative, we ask the patient to grade
the severity from ‘‘slight’’ to ‘‘overwhelming’’ and, further,
to describe the taste change (e.g., bitter, bland/absent,
metallic, etc.). We suggest that clinicians incorporate taste
changes into their routine symptom inventories. Although
the Taste Plate is not a screening instrument in itself, it may,
nonetheless, act as a clinical prompt to screen for this under-
recognized symptom.
The second step is to consider a differential diagnosis of
the etiology of taste alteration other than CKD. Other eti-
ologies may include oropharyngeal lesions or being second-
ary to chemotherapy or radiotherapy. The presence of a
lesion necessitates a medical review. Third, if it is concluded
that the underlying CKD is the sole or primary reason for
the taste alteration, then use the Plate to plan management
moving from the inner to the outer circle. This sequence is
set out in Figure 2.
Role of the Renal Dietitian
The role of the renal dietitian in the overall management
of ESKD is critical.6 Ultimately, the principal responsibility
for guiding the dietary intake of the patient rests with the
dietitian. The Plate does not replace the work of the renal
dietitian but rather, it guides the dietitian (and other clini-
cians) in planning the management of taste alterations. In
particular, the Plate will be a useful tool for non-dietitians
(i.e., doctors and nurses) involved in the care of these pa-
tients to allow them to provide preliminary advice prior
to consultation with a dietitian or in the absence of access
to a dietitian.
 A TOOL FOR TASTE MANAGEMENT: CKD TASTE PLATE 3

Table 2. Summary of Taste Changes, Proposed Pathophysiological Mechanism, and Empirical Management in Patients With
Chronic Kidney Disease
Taste Change Proposed Mechanism Proposed Management

Salty taste High concentration of salivary sodium
stimulates type I taste cells
Metallic taste High concentration of urea
Urea converted, by bacterial ureases,
into ammonia and carbon dioxide
(CO2)
Bitter taste High concentration of urea activates
bitter-specific type II taste cells. Note
there is a genetic variability in
sensitivity to urea
Loss of taste High concentration of salivary sodium
May be a complete loss of taste (ageusia) stimulates type I taste cells. These
or the loss of individual taste(s). cells secrete K1 inhibiting type II and III
Ageusia may be due to a single taste cells. This reduces sensitivity to
mechanism affecting all taste buds or sour, umami, and bitter/salt
the suppression of all tastes by Complete ageusia may be due to salivary
individual mechanisms zinc deficiency
Loss of sour taste High concentration of bicarbonate
reduces the presence of H1 and
reduces the stimulation of type III taste
cells
Loss of umami taste (e.g., cannot taste High concentration of salivary
meat) bicarbonate
Adapted from Brennan F, Stevenson J, Brown M. J Ren Nutr. 2020;30:368-379.3
Salt restriction to change threshold
Sweet tastants in an attempt to activate
sweet-sensitive type II taste cells. In
addition to classic sweet tastants
consider tomatoes and beetroot
(contain 4% and 10% carbohydrates,
respectively)
Avoid metallic cutlery
Sodium bicarbonate mouth washes.
Prior to meals—menthol (mints), ginger
beer, fruit juices, and tea
Avoid bitter tastants, e.g., coffee,
chocolate, and beer
Sweet tastants. The activation of sweet-
sensitive type II taste cells shuts down
bitter taste. Increase sweet/
carbohydrates in diet (cook with
honey, fruit juices, tomatoes, beetroot)
Activate type III taste cells by acidic
foods, drinks, and condiments (see
below). Acidity enhances sour taste,
counteracting bitter taste
Attempt to enhance taste by: adding
herbs and spices, including chili and
pepper; activate type III taste cells by
lemon, lime, carbonated drinks,
vinegar. Example: marinating meats,
chicken, or fish with spices or lemon
juice. Activate sweet-specific type II
taste cells (cook with honey, fruit
juices)
Trial of zinc supplementation
Reduce sodium intake
Trial of acidic foods like grains, lentils,
kiwi fruit, and blueberries, and acidic
drinks like lemon, carbonated drinks,
acidic condiments, and vinegar
Trial of acidic foods, drinks, and
condiments (as above)
Tongue movements

Aligning Taste Management Strategies With Implications for Upper Gastrointestinal

Appropriate Dietary Recommendations
In the management of taste alteration in CKD, a tension
may exist between recommendation(s) made by clinicians
and the overall CKD dietary recommendations. For
instance, food A, beverage B, or condiment C may be
appropriate suggestions to improve disordered taste but
may contain excessive potassium, sodium, or phosphate.
Ensuring that taste recommendations are appropriate to
the patient’s other clinical concerns, such as serum potas-
sium and phosphate, was an important step in the process
of the development of the Plate.
Symptoms
Patients with ESKD report a range of upper gastrointes-
tinal (GIT) symptoms including anorexia, nausea, vomit-
ing, and early satiety.7 The pathogenesis of these
symptoms is complex. Factors causing or contributing to
these symptoms include medications, electrolyte distur-
bances, constipation, and uremia (secondary to inadequate
dialysis or, if the patient is being managed conservatively,
without dialysis). Certainly, patients reporting taste changes
also report a high number and severity of other upper GIT
symptoms, such as anorexia, nausea, vomiting and dry
4 BRENNAN ET AL

Figure 1. The chronic kidney disease (CKD) taste plate. (For interpretation of the references to color in this figure legend, the
reader is referred to the Web version of this article.)

mouth.2 However, the extent to which alterations in taste
contribute to these symptoms is unknown and whether
there is a causal pathway remains unclear. There appears
to be a complex interaction among taste alteration, salivary
composition, and upper gastrointestinal symptoms in CKD
patients.5 The use of mouthwash solutions shows promise
in ameliorating both taste changes and associated GIT
symptoms, such as nausea and dry retching.8
The Importance of the Family and Caregivers
The consumption of food and drink is a far more com-
plex process than a purely physical one. Cooking for, and
sharing the collective experience of, eating and drinking
has profound social and cultural dimensions.9 Eating food
and drinking are a necessity, comfort, celebration, condo-
lence, and expression of welcome and love. Patients with
ESKD who live with their families do not sit in isolation
 A TOOL FOR TASTE MANAGEMENT: CKD TASTE PLATE 5

Table 3. Case Studies in the Use of the CKD Taste Plate

Case study 1
Pa ent is screened for taste altera on.
John is a 70-year-old man with diabetic nephropathy. He has
received hemodialysis for 5 y. Over the years he has been
progressively troubled with a bitter taste. Occasionally, he
reports ‘‘losing all my taste.’’ His clinicians are not sure what
causes this symptom and how to manage it. John struggles
with eating meals, is nauseated with certain foods, and has
lost weight
Here the predominant taste change is a bitter taste. The
proposed mechanism of bitterness is a high concentration
of salivary urea that activates bitter-specific type II taste
cells. Turning to the Plate, the clinician should locate the Pa ent reports taste altera on
section of the inner circle of the Plate marked ‘‘bitter’’ and
then look at the outer (management) circle adjacent to the
‘‘bitter’’ area. Various suggestions are made, including:
1 Avoiding bitter foods and drinks
2 Trial the inclusion of acidic or carbohydrate-based
condiments, foods, and/or drinks
Physiologically, bitter tastes can precipitate nausea,
vomiting, and dry retching. Therefore, an improvement
Are there any oropharyngeal lesions
in bitter taste may lead to an improvement in these
or other condi ons that may induce
upper gastrointestinal symptoms. John may be left with
a residual of taste absence. The clinician could turn to taste altera on?
that section of the inner circle of the Plate and then to
the proposed interventions in the outer circle, adjacent
to the ‘‘Absent/bland taste’’ section
Case study 2
An 80-year-old woman has ESKD secondary to ischemic No
nephrosclerosis. After discussion with her family and Yes
nephrologist, she decides to be managed on a conservative,
non-dialysis pathway. After many clinic visits where the
subject of upper gastrointestinal symptoms are raised but
not the subject of taste, she reports no taste ‘‘for a long
time.’’ She states ‘‘I really need to force myself to eat. My Medical
taste has gone.’’ review
Here the clinician should start in the inner circle marked
‘‘Absent or bland taste,’’ then look at the various
suggestions set out in the corresponding part of the outer
circle. Those suggestions include:
1. Trial of cooking with spices, chili, vinegar, and marinades According to the descrip on of
to stimulate taste
2. Trial of high sucrose or glucose carbohydrates to stimu- the taste altera on -
late sweet taste buds. Care should be exercised in pa-
tients with diabetes mellitus
a plan of management based on the
3 Incorporate acidic foods to activate sour taste buds
4. Avoid excess salt CKD Taste Plate
5. Trial of zinc supplementation
Figure 2. A proposed sequence of screening and manage-
CKD, chronic kidney disease; ESKD, end-stage kidney disease.
ment of taste alteration in CKD. CKD, chronic kidney disease.
(For interpretation of the references to color in this figure
legend, the reader is referred to the Web version of this
from them. Families and caregivers worry about the intake article.)
of their loved ones and, in illnesses such as ESKD, the need
to nurture by feeding is often encumbered by symptoms
such as anorexia and taste changes.2,10 With poor oral necessary to allow meal adjustment that does not isolate
intake, both patients and families become frustrated and the patient from the rest of their family.
may despair. The Plate may be used as a guide to assist fam-
ily and friends in normalizing patients’ taste and to assist in Limitations
preparing meals. The advice contained in the Plate should Throughout the process of designing the Plate we recog-
reinforce the dietary recommendations of the dietitian; nized that the approach was inherently inexact. First, the
however, flexibility, creativity, and common sense may be clinician relies on the clarity and reliability of the response
6 BRENNAN ET AL
of patients in self-reporting taste changes. Another limita-
tion is the paucity of evidence. Although most of the rec-
ommendations included in the Plate are made by
dietitians based on years of collective experience, there
have been no studies examining the effect of different foods,
beverages, or condiments on taste alteration in CKD. Our
recommendations emerge from a strategy based on the
physiology of taste and pathophysiology in ESKD. Given
that we have an incomplete understanding of both, this
approach has its limitations. Nevertheless, the Plate moves
beyond empiricism to an attempt to tie pathogenesis to
management.
Future Steps
Much more needs to be known in both pathophysiology
and management. Future areas for research that flow from
the development of the Plate include the evaluation of
the following:
 Content validity by external judges
 The application of the Plate for clinicians, patients,
and families
 Whether these strategies result in an improvement of
taste and/or other upper GIT symptoms
 Whether a tool as this improves identification and
self-efficacy of clinicians in managing taste changes.
Practical Application
This clinical tool could be used by multi-disciplinary
renal health professionals, particularly dietitians, in aiding
the management of alterations in taste. It provides practical
and specific examples of potential strategies that should be
systematically trialed with patients.
Conclusion
Taste alteration is a common and burdensome symptom
of ESKD. This paper introduces a new clinical tool, the
View publication stats
CKD Taste Plate, to aid clinicians in dealing with this com-
mon and difficult problem. The tool is based on aligning
specific taste descriptors with management based on the
postulated mechanism of these alterations.
Acknowledgments
The authors would like to thank ‘‘InHouse Print’’ and renal clinicians
who provided valuable feedback for the development of the CKD Taste
Plate graphic.
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