Clinical nutrition
Perspectives on the Nutritional Management of Renal Disease in Asia: People, Practice, and Programs

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The high prevalence of end-stage renal disease (ESRD) in many Asian countries is attributed to diabetes and hypertension. Health care expenditure in relation to per capita income and government share of this expenditure vary among Asian countries and are affected by large populations and the poverty factor. The impact of ESRD on nutritional management in Asia reveals the need for clinicians to balance the requirements for higher standards of dietetic practice as they implement optimal care algorithms with the goal of improving outcomes, against the backdrop of staffing limitations, limited expertise in renal nutrition practice, and cultural diversity among Asian people. This paper discusses current aspects of dietetic practice and the likelihood that a change in practice is required if dietitians are to play an active role in preventing or slowing down ESRD.

Section snippets

Incidence of End-Stage Renal Disease in Asia

End-stage renal disease (ESRD) has been diagnosed in an estimated 347,538 patients in Asia, but globally, Taiwan has the highest incidence (384 per million) and Japan ranks fourth (262 per million). Of cases in which diabetes mellitus is the primary cause, Malaysia emerges with the highest incidence.3 Of concern is the high incidence of diabetes in Asia (Fig 1), viewed in terms of the limited per capita health expenditure (Table 1). Incidence and prevalence rates of ESRD reported reflect

Treatment Modalities

Dialysis is a major option in most Asian countries and is mainly supported by government or nongovernment organization (NGO) subsidies.3 With the exception of Hong Kong, where peritoneal dialysis (PD) is the norm (82%), maintenance hemodialysis (MHD) predominates in most Asian countries (Fig 2). Lack of affordability and Asian culture mean that kidney transplantation is a limited option.

Nutritional Status

The nutritional status of patients with ESRD in Asia is scarcely reported. A cross-sectional survey of 28 hemodialysis (HD) facilities (n = 140 patients) in the Republic of Korea reported on dialysis and nutrition practices.5 The prevalence of undernutrition (body mass index [BMI] <18.5) was 13%, 5% of patients experienced moderate malnutrition (70% to 80% of ideal body weight [IBW]), and 35% were below the criterion for serum albumin (Ser Alb, 4.0±0.4 g/dL).

The National Renal Registry (NRR) of

Practice

In the Korean study, 17% of patients underwent nutritional assessment by a physician, nurse, or dietitian, and the likelihood of this event was enhanced at hospitals in an urban setting.5 Although 94% of patients received initial nutritional instruction, only 6% were followed over the long term. Nutritional assessment was uncommon in rural areas and in free-standing dialysis units, in part because of a lack of skilled professionals. In Malaysia, wide variations in nutritional indices have been

Programs

Renal transplantation that costs $6,000 ($US) is cheaper than dialysis in India, but the recurring cost of immunosuppression is a drain on family income. Given the rising tide of ESRD, prevention of ESRD at the grass roots level is the objective of Mani and coworkers in India.10, 11 Through the Kidney Help Trust, a 25,000-strong rural community is regularly screened for identification and monitoring of diabetes and hypertension. With this model, the prevalence of impaired renal function

Conclusions

One can speculate on the reasons for minimal participation of Asian dietitians in renal services. For example, limited staff numbers to cover all medical departments prevent specialization of skills. The rotation of dietitians through various postings also limits advancement of skills and participation in the multidisciplinary team, resulting in the perception that dietitians are minimal stakeholders in renal care. However, given the rising incidence of ESRD and the limited health care

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Copyright © 2007 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.