By Carolyn Crist

(Reuters Health) – Patients with chronic kidney disease could slow the progression of their illness and delay dialysis through nutrition therapy, according to a new article in the Journal of the Academy of Nutrition and Dietetics.

For a host of reasons, however, only 10 percent of non-dialysis kidney disease patients in the U.S. ever meet with a dietician, the authors write in a review of the evidence for nutrition therapy, obstacles to getting it and possible solutions.

“Kidney disease is increasing with the obesity epidemic and aging population, and it’s one of the most expensive diseases, even if the patient isn’t yet on dialysis,” said lead author Dr. Holly Mattix-Kramer of Loyola University Medical Center in Chicago.

Chronic kidney disease currently affects about 15 percent of the U.S. population, or 30 million people, the authors note. But among people aged 65 or older, about half are expected to develop kidney disease in their lifetimes.

Kidney disease is already more expensive to treat than other chronic conditions, such as stroke, the authors write. But when it reaches advanced stages, costs double.

Only about 650,000 people in the U.S. are in the end-stage of kidney disease, which requires dialysis, yet Medicare costs for dialysis exceed $33 billion annually, Mattix-Kramer and her colleagues write.

“It’s important to find ways to prevent the disease from developing, or if someone has it, to slow their progression to going on dialysis,” she told Reuters Health by phone. “Nutrition therapy is not a panacea, but it can help.”

Mattix-Kramer and colleagues review the evidence on medical nutrition therapy (MNT), which is an individual nutrition assessment that includes planning and dietary education by a registered dietician. For people with kidney disease, decreasing intake of protein, phosphorous additives and salt can slow the progression of the disease. Due to risks of malnutrition and high potassium levels, however, patients should work with a dietician to strike a careful balance, the authors add.

“Kidney disease should be viewed as a nutritional disorder, but unfortunately, it’s not often seen that way and an abysmal number of patients see a dietician,” Mattix-Kramer said. “We believe the majority of people – physicians and patients alike – don’t realize the benefits.”

In 2000, the Institute of Medicine recommended medical nutrition therapy for patients with several diseases, including diabetes and kidney disease. Currently, Medicare Part B covers this therapy for kidney disease patients not on dialysis, but few patients use it. Many state Medicaid programs and private insurers offer coverage as well.

Mattix-Kramer and colleagues think barriers to use of this benefit include a lack of awareness, lack of doctor referrals and a lack of available appointments. Some dieticians may perceive the Medicare enrollment process as complex and burdensome, they add.

In addition, “some health centers and practice settings opt not to provide MNT because of low reimbursement for services,” said Desiree de Waal of the University of Vermont Medical Center in Burlington, who runs a nutrition clinic for kidney disease but wasn’t involved with the review.

“Patients often come to me because they are confused about what they have read about diet in kidney disease,” she told said by email. “They often have more than one chronic disease and would like me to streamline the diets to make it easier for them to follow.”

Since registered dieticians are not typically based in the same office as kidney specialists, patients may find it difficult to schedule an additional appointment or arrange transportation. Phone and video counseling are not currently covered under Medicare unless the patient lives in a rural area.

Mattix-Kramer and colleagues suggest several solutions for the future. Kidney disease specialists could incorporate registered dieticians into their healthcare teams, and private practices could incorporate MNT services. These collaborations likely depend on ongoing changes in payments via the Affordable Care Act, they write.

“We need to do what cancer doctors do – we may not be able to cure kidney disease, but we can control it,” said Dr. Kamyar Kalantar-Zadeh of the University of California, Irvine School of Medicine, who wasn’t involved in the review.

“As an analogy, dialysis therapy is like chemotherapy,” he said in a phone interview. “If we can manage kidney disease with nutrition and delay dialysis, let’s recommend that instead.”

SOURCE: Journal of the Academy of Nutrition and Dietetics, online July 31, 2018.