Diet Counseling (Medical Nutrition Therapy) Referral Form Page 2

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Rationale for Data Inclusion
The following information explains why it is important to include data for various sections of the CKD Diet
Counseling Referral Form.
BLOOD pRESSURE
Uncontrolled blood pressure is associated with more rapid progression. Control of hypertension
is also a key opportunity to slow the rate of progression of chronic kidney disease (CKD).
RECENT WEIGHT CHANGE
Trend in weight status is critical for assessing inadequate intake (loss) or fluid retention (gain).
FOR DIABETICS
Presence or absence of diabetes is critical to establishing an etiology for kidney disease and risk for
progression. Duration of diabetes is useful for determining the likelihood that the patient’s CKD is
caused by diabetes.
ALBUMINURIA
The presence and quantity of albuminuria may be used to assess kidney damage. High levels
of albuminuria are associated with more rapid progression of CKD and loss of renal function.
URINE ALBUMIN-TO-CREATININE
Persistently elevated levels of urine albumin are used to identify and quantify kidney damage.
RATIO (UACR)
High UACR levels are associated with more rapid progression to kidney failure. Generally reported
as milligrams albumin/ grams creatinine, monitoring trends in UACR may be useful when educating
patients about self-management efforts and prognosis.
ESTIMATED GLOMERULAR
eGFR is used to assess kidney function. The rate of eGFR decline varies by etiology and among
FILTRATION RATE (eGFR)
individuals with the same etiology. A decrease in the rate of decline of eGFR may reflect response to
therapy. Monitoring trends in eGFR may be useful when educating patients about self-management
efforts and prognosis.
Presence or absence of hyperkalemia is useful when determining potassium prescription.
SERUM pOTASSIUM (K)
Potassium restriction is not indicated in the absence of hyperkalemia.
SERUM BICARBONATE (HCO3)
A low level, defined as < 22 milliequivalents per liter, may indicate metabolic acidosis in CKD
and may reflect reduced acid excretion and reduced base production by the kidneys.
BLOOD UREA NITROGEN (BUN)
Increasing blood urea nitrogen levels may indicate reduced clearance of nitrogenous waste.
SERUM CALCIUM (Ca)
Calcium levels are used to assess and monitor abnormal mineral metabolism and bone disorders
in CKD. Vitamin D supplements may be prescribed for hypocalcemia. Use of vitamin D may
increase the risk for hypercalcemia.
SERUM pHOSpHORUS (phos)
Phosphorus levels are used to assess and monitor abnormal mineral metabolism and bone
disorders in CKD. Use of vitamin D may increase the risk for hyperphosphatemia.
HEMOGLOBIN (Hgb)
Patients with CKD are at risk for anemia due to reduced levels of erythropoietin, a hormone
produced by the kidneys. Iron studies may be indicated prior to iron supplementation
or use of erythropoiesis-stimulating agents.
LOW DENSITY LIpOpROTEIN (LDL)
LDL levels are used to assess and monitor dyslipidemia in CKD.
HIGH DENSITY LIpOpROTEIN (HDL)
HDL levels are used to assess and monitor dyslipidemia in CKD.
TRIGLYCERIDES (TG)
Triglyceride levels are used to assess and monitor dyslipidemia in CKD.
INTACT pARATHRYOID HORMONE
iPTH is used to assess and monitor abnormal mineral metabolism and bone disorders in CKD.
(ipTH)
Levels may be reduced with vitamin D supplementation.
VITAMIN D (25-hydroxy vitamin D)
Patients with CKD are at risk for hypovitaminosis D due to reduced levels of 25-OH Vit D as
well as decreased 1-OH activation in the kidneys.
SERUM ALBUMIN (Alb)
Albumin may be useful to assess and monitor nutritional status in CKD. Hypoalbuminemia is
associated with inflammation and poor prognosis in CKD.
CURRENT MEDICATIONS
Medication lists are crucial to assess for medication-nutrient interactions and patient
self-management education.
The National Kidney Disease Education program (NKDEp) is an initiative of the National Institute of Diabetes and Digestive and Kidney
Diseases of the National Institutes of Health. For more information on CKD, go to
chronic-kidney-disease-ckd.

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