Liberalized Renal Diets in Long-Term Care Facilities

The American Dietetic Association recommends that long-term care facilities liberalize therapeutic diets to maximize meal intake of residents who are at nutritional risk. In many cases a regular diet improves meal intake, minimizes struggles over dietary compliance, and improves a patient’s quality of life.  The National Kidney Foundation recommends 2-3 grams of potassium and limiting milk and dairy to one serving (8 ounces milk or one equivalent dairy serving) per day for individuals on dialysis; furthermore, in long-term care, it is recommended that citrus, bananas, tomato products and potatoes are restricted*.  With appropriate assessment and monitoring by a registered dietitian, a general/no added salt diet with no baked potatoes, fresh tomatoes, oranges, orange juice and bananas and limiting milk and dairy to one serving (with texture modifications) is appropriate for many long-term care residents with chronic kidney disease.  The National Kidney Foundation recommends at least 1.2 grams of protein per kilogram of body weight with at least 50% high biological value for residents receiving hemodialysis.

The goals of nutritional management of chronic kidney disease across the continuum of care include delaying the progression of kidney disease, preserving protein and nutritional status, minimizing complications and symptoms, and maintaining blood chemistries.  The following steps can be taken in long-term care to ensure proper nutrition:

1. Residents will be admitted on the diet that was recommended on the hospital discharge summary. Diet orders on discharge summaries should be converted to the correct corresponding house diet. If no diet is specified, a regular diet (with appropriate texture modifications) will be ordered by the admitting nurse.

2. A dietary communication slip with the resident’s diet order on it will be sent to the kitchen.

3. The facility nutrition professional (registered dietitian, certified dietary manager, or dietetic technician) will complete a nutrition assessment of the resident as per facility policy.

a. Information about the resident’s history of dietary restrictions will be obtained through patient/family interviews. 

b. Food likes and dislikes will be obtained through patient/family interviews.

c. Meal intake will be observed.

4. The facility nutrition professional will recommend a therapeutic diet if it appears necessary and/or appropriate for a resident.

a. Most residents will benefit from a regular diet
b. Fluctuations in blood sugars can be managed by adjusting medications.
c. Residents with renal failure and/or congestive heart failure may benefit from therapeutic diets or regular diets with certain foods listed on tray cards as foods to avoid.

5. The facility registered dietitian (consultant or full-time position) will review recommendations to assure they are appropriate for each resident if another nutrition professional completes the original nutrition assessment.

6. At each quarterly review, the nutrition professional will determine if the diet prescription remains appropriate for each resident. The plan of care will be adjusted if necessary.

7. If weight loss and/or poor intake are noted by residents on therapeutic diets, liberalizing to a regular diet in an attempt to improve meal intake is an accepted and recommended intervention.

8.  Annual continuing education will update new staff on a liberalized renal diet.