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CKD Diet Counseling (Medical Nutrition Therapy) Referral Form

NKDEP encourages collaborative management and communication between primary care providers (PCPs) and registered dietitians (RDs) to help improve patient outcomes.

The interactive CKD Diet Counseling (Medical Nutrition Therapy) Referral Form (PDF, 569 KB) is designed to help referring PCPs share important patient data with the consulting RD. While all PCPs can use this form, Medicare requires a physician order for dietitian reimbursement for MNT. The form can be saved to a computer, edited, and shared electronically with the RD.

Remember to save the form to your computer before entering data. Also, to comply with the Health Insurance Portability and Accountability Act of 2002, please protect the personal health information contained in the completed form.

Rationale for Data Inclusion

The form provides fields for entering data that are likely to be useful for patient evaluation. The following information provides the rationale for why this information is important.

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 RATIO (UACR):

Persistently elevated levels of urine albumin are used to identify and quantify kidney damage. 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 FILTRATION RATE (eGFR):

eGFR is used to assess kidney function. The rate of eGFR decline varies by etiology and among 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.

SERUM POTASSIUM (K):

Presence or absence of hyperkalemia is useful when determining potassium prescription. 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):

iPTH is used to assess and monitor abnormal mineral metabolism and bone disorders in CKD. 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.

October 10, 2012​​​​

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You can also order print versions from our online catalog.