Sally Campoy:(председатель или председательница, как менее обидно для феминисток?) And now to our other member of this multidisciplinary team, the dietitian. I know for those of you work in dialysis, you really depend on the dietitian and we also depend on the dietitian in the chronic kidney disease clinics as well. Kathy Lane is a renal dietitian for GAMBRO Health Care in Richmond, Virginia. She also provides a renal rotation for the Medical College of Virginia Hospital's dietetic interns. Ms. Lane received a bachelor of science degree in dietetics from West Virginia University in Morgantown, West Virginia. She's been a member of many professional dietetic organizations and has been an officer. She's also cared for the nutritional needs for patients all across the continuum of renal disease from hemodialysis, peritoneal, and transplant, and she also has been involved in chronic kidney disease. So please join me in welcoming Kathy Lane.
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Kathy Lane
RD
Kathy Lane: Hi. Thank you very much, Sally. My title of this evening is Hidden Areas of Noncompliance. And I think there are lots of areas that we don't think of as to why patients are noncompliant or why they may be nonadherent to their diet.
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Hidden area of noncompliance There are a number of hidden areas of noncompliance, and number one is ignorance. And this may be due to a lack of education-maybe we haven't provided that to the patient. There are a number of reasons for ignorance: maybe they've resisted our teachings and our education.
Secondly, there's certainly an area of denial involved. Patients who don't particularly feel sick or maybe still have a pretty good urinary output. It's easy to deny the fact that they have kidney failure and think that it may go away when indeed it won't. The patient must take ownership to this problem themselves. Oftentimes I have patients come in for education, and they want to put it over to another family member. Well, my wife will take care of my diet. Talk to her. This really isn't a great idea, and I try to get the whole family involved. Family support is good, but the patient is primary. They've got to make the decisions when they're out to eat. They've got to make a decision at a friend's house. So they must really take ownership for their diet. They're the ones who will suffer if they don't comply.
During the first interview with a patient, it has to be a really in-depth interview. I need to find out a lot of information, and normally I try to get the patient to talk as much as they will, because I need to know about their cultural habits. Are they used to eating beans and potatoes and corn bread? Do they have a Mexican influence, and do they like beans and cheeses? Or if they come from the southern states or Florida, they may enjoy the citrus fruits and the tropical fruits. All these are important for me to know. I also talk to them about any odd preferences or unusual cravings. We have patients with picas who may crave corn starch or clay or different things. There's lot of things that I need to know in that first interview. So I try to get an in-depth dietary history.
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Hidden area of noncompliance Anemia can be another reason for noncompliance. If the patient's anemic, they generally do not feel well. They may not feel like preparing their meals as they should. They may be very tired and lethargic, so we have to get the anemia corrected in order that they can better comply with their diet. I do address issues besides epoetin alfa and iron being very important issues in correcting anemia, nutrition is also a very important issue. If the patient's not taking in adequate protein, if they're not getting adequate iron in their diet, then they may require very high doses of epoetin alfa or they may not respond to the epoetin alfa therapy as they should. Potassium is another issue that we look at early in treatment. If a patient is on a diuretic then they may not require potassium restriction very early. But if, for instance, the physician tells me I'm going to put this patient on an ARB or ACE inhibitor, then we need to know that. I need to look for their potassium levels and teach early on what kind of things besides bananas and oranges that they need to limit in their diet.
Fifth, this is a tough one. Phosphorus is probably the most difficult of all the issues in dietary compliance. Phosphorus is in practically all foods, and we have a lot of difficulty getting compliance with phosphorus control. For instance, cheese and dairy products are major phosphorus contributors. Beer can be a major phosphorus contributor. If you have a patient who enjoys his six-pack on the weekend, that could mean trouble. So phosphorus control is very difficult. We also have to teach about the binders and taking those at mealtime, taking them along when you eat out or whatever.
The outcomes. I can't tell you enough how much I appreciate the outcomes from our patients attending the pre-ESRD clinics or the CKD clinics. We get a lot of positive outcome from that. The patient is generally better prepared, they're not as nervous, they understand what's going to happen to them once they do get to dialysis. The diet becomes a gradual process versus a sudden process. And they improve their anemia, so they're more alert, they feel better. PTHs are much better, so there's a lot of positive outcomes from this. And so I strongly feel that early intervention and education can make all the difference. There are a lot of dialysis folks out there, and I can guarantee that it'll make your job a lot easier if these people get some education early on. Thank you.
