A Day in the Life of a Nephrology Dietitian

Christine Crow, RD, LD

As the number of people diagnosed with diabetes and hypertension increases within the United States, so does the number of dialysis patients. With all of the changes in health care regulations and the American dialysis population reaching over 430,000 patients (United States Renal Data System, 2013), the responsibilities of a nephrology dietitian are expanding. The dietitian's role in a dialysis clinic extends far beyond the nutritional status of the patient. Not only do nephrology dietitians analyze protein and calorie intake, albumin, and potassium levels, but they are also responsible for vitamins; nutrition supplements; phosphorus, calcium and parathyroid hormone levels; phosphorus binding medications; sodium; and fluid restrictions. They assess and analyze blood pressure, amount of fluid removal, interdialytic weight gains, hemoglobin, dialysis adequacy and accesses. These patient health indicators are just the beginning of a dietitian's strategic clinical assessment when diagnosing the root causes of nutritional problems and overall health status.

Few dialysis patients present to the clinic without a plethora of other medical problems. Diabetes, hypertension, hypercholesterolemia, heart disease, cancer, hepatitis, amputations, and major depression are frequently seen in patients' medical records. In addition, one must not forget the social struggles that patients also deal with on a daily basis. With medical and pharmacy bills accumulating, many patients also struggle with financial hardship. They sometimes face a choice between medications, mortgages and food which make it even more challenging to afford the healthy foods recommended in the renal nutrition plan. The proverbial obstacle course of comorbidities and social struggles can greatly impact chronic kidney disease patients and must be considered by the nephrology dietitian when assessing their nutritional status. Thankfully, a dialysis clinic is armed not only with the life-saving dialysis machines and medications, but with a team of professionals that will help the patient manage all of their medical conditions. When working toward creating an improved life for our patients, nephrology dietitians collaborate with nephrologists and advanced practitioners, social workers, nurses, and dialysis technicians, each of whom bring a special skill set and knowledge base to the team.

When meeting with this specialized team of professionals, nephrology dietitians examine laboratory results, medication lists, and weight gains in preparation of moving out of the office and into the dialysis clinic with the tools, action plans, and motivation to help patients feel better and live longer. Dietitians have nutrition and medication changes in mind, along with the laboratory reports and coordinated handouts needed to sell an action plan to the patient. How could patients refuse dietitians' help in improving their lives? As most have experienced, the patient that excitedly welcomes the dietitian with open arms, listening to her every word and ready to make any and all recommended changes, is an anomaly. Often times, patients do not feel well, are tired, and trying to comprehend the medication or treatment changes recently made by their doctor for another health issue that they are trying to manage, not considering that it may be affected by what they are eating or drinking. With their mind racing about other health woes and personal issues, sometimes the last thing they are worried about is how they can change their current nutrition intake. In fact, the nutrition choices that they make are sometimes the only aspect of their lives they may feel that they have control over. This is when dietitians are challenged to accept that not every patient may be as excited or motivated to change the direction of his health as they are. Does this mean that all of the collaborative efforts as a healthcare team are wasted and the patient is doomed for nutrition failure? Absolutely not! It means that dietitians now have the opportunity to demonstrate their ability to counsel empathetically and utilize their motivational interviewing skills in order to create behavior change. The most knowledgeable dietitians cannot be effective if they are unable to communicate their expertise and counsel their patients to make a change. These are skills that may have been introduced in the classroom, but can only mature in clinical practice with patience and a lot of practice! Thankfully for the nephrology dietitian, we get ample experience in practicing our motivational interviewing skills so that we can empower our patients to develop realistic goals and create change. Although the dietitian may not get the opportunity to check off everything on the agenda, it is crucial to remember that dietitians work with individual cases. These individuals may not have a medical degree but they are the most important advocate and part of their health care team. Therefore, nephrology dietitians are frequently forced to look beyond their own agendas and ensure the patient needs are paramount. It is important to incorporate patient food preferences, cooking abilities, and overall health goals when counseling the patient towards positive behavior change.

As previously mentioned, nephrology dietitians work and collaborate with many different professionals, and are often times the only dietitian in a clinic. This allows the nephrology dietitian to demonstrate not only expertise, but leadership skills on a daily basis. Many nephrology dietitians may not have been awarded an official leadership title, but no title is needed for dietitians to guide their dialysis clinic towards healthier patient outcomes. Nephrology dietitians are leaders through the behaviors and communication skills utilized in daily conversations with patients, and express leadership through educating not only patients, but also coworkers. Nutrition change can be difficult for any person to overcome and dietitians need support from their coworkers to reinforce the importance of achieving nutrition and health goals. In order for the dietitian and patients to receive the support needed from all health care professionals, it is essential that the dietitian educate the staff on all aspects of the renal nutrition plan and the consequences of non-adherence. In addition to educating our fellow professionals, we also empower them to utilize their skills and patient rapport when having those difficult conversations with patients regarding their nutrition intake, medications, and the consequences of non-adherence.

With our growing list of responsibilities and health outcomes to manage, nephrology dietitians are never without a challenge in their role as experts and leaders in many aspects of the patient's health. Although overwhelming at times, these responsibilities only increase the impact dietitians can make with their patients—this is the most rewarding part of being a nephrology dietitian. In between all of the meetings and lab reviews, dietitians are building relationships with patients and their families. These relationships, and truly caring about dialysis patients and their quality of life, are what inspire dietitians to educate and encourage without ever giving up, and drives them to analyze reports looking for new causes or ideas to help solve a problem. In addition, dietitians create new educational handouts, games, or displays, search for new recipes or supplements, and continue to have those difficult conversations with patients (that, often times, they don't want to hear). The strength of the patients to come back to the chair three days per week inspires dietitians to support, educate, and encourage them to continue their fight for better health and well-being.

References

United States Renal Data System. (2013). USRDS 2013 Annual Data Report: Atlas ESRD Volume 2. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease: Bethesda, MD.