Patients who progress to hemodialysis often enter a world where following dietary instructions can be difficult. There are now new goals for dietary protein intake on dialysis (1.0-1.2 g/kg body weight per day) versus for those with chronic kidney disease (CKD) Stage 3-5 (anywhere between 0.55–0.8 g dietary protein/kg body weight/day), depending on if they have diabetes or not.
The National Kidney Foundation‘s Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Nutrition in CKD emphasize the importance of collaborating with a registered dietitian nutritionist in order to meet nutritional goals in the realms of limited sodium intake, potassium intake, and acid loads.
Limiting factors to acceptance of dietary recommendations include access to a nutritionist, complexity of information, social support, and cultural food considerations. Especially in view of the COVID 19 pandemic, there has been a need to approach patient care with innovative techniques and technology. There has been a drastic uptick in not only the use of telemedicine, but also the use of mobile devices and internet access in general.
With this in mind, a six month randomized feasibility study (KIDNEYTEXT) by Dawson et al set out to see if a mobile phone text message intervention could improve dietary behavior in people on hemodialysis. The centers were in Australia and the primary outcome was feasibility, acceptability, and adherence to dietary recommendations. Secondary outcomes analyzed objective clinical parameters such as serum potassium, serum phosphate, interdialytic weight gain, quality of life, blood pressure, albumin, PTH, HgbA1C, and medication usage (of phosphate binders, sodium polystyrene sulfonate, anti-hypertensives, and diuretics). The text messages were unidirectional, with the subjects of the texts including advice, information, motivation, and general health eating behaviors. There were 462 patients screened; of the eligible patients 48% consented to participate. Notably, 16% of patients screened were not eligible owing to not having access to a mobile phone or insufficient English language proficiency.
Similar studies have been done in the CKD 3-4 population with similar themes of increased patient engagement, convenience and practicality, increased awareness and confidence in dietary choices, and overall satisfaction. The primary outcome in this study from Dawson et al showed that the study was feasible, accepted by participants, and had high self-reported levels of satisfaction. The question then becomes what objective measures can be achieved with such a program. Adherence to dietary guidelines, albeit via self-reporting did not reach statistical significance. There was also no difference between the two arms in terms of serum potassium, albumin, urea, bicarbonate, PTH, or HbA1C. Very modest changes in phosphorus (slightly lower by 0.19 mmol/L) and higher likelihood to meet interdialytic weight gain goals (OR 6.23) in the intervention groups were noted.
Finding innovative ways to connect with and guide patients outside of the office or dialysis unit—especially in the COVID era and digitized world—is an interesting and promising concept to explore. One of my favorite studies is one where health promotion by barbers in Black-owned barbershops working with specialty trained pharmacists led to a larger blood pressure reduction in those with uncontrolled hypertension. Perhaps a trial where patients can respond back with questions of their own would be more engaging and lead to even more finite outcomes? This trial is a promising step in the right direction, creatively leveraging technology to the benefit of patient care and outcomes. Combining this with face-to-face interventions with nutritionists can complement traditional dietary education and provide an option for patients with limited resources.
Title: A Text Messaging Intervention for Dietary Behaviors for People Receiving Maintenance Hemodialysis: A Feasibility Study of KIDNEYTEXT
Authors: Jessica Dawson, Katrina L. Campbell, Jonathan C. Craig, Allison Tong, Armando Teixeira-Pinto, Mark A. Brown, Kirsten Howard, Martin Howell, Rabia Khalid, Kamal Sud, Aravinda Thiagalingam, Clara K. Chow, Vincent W. Lee