Implementation of an Evidence-Based Renal Nutrition Practice Guideline: The AUGmeNt Study

This study aimed to (1) assess implementation of selected recommendations from the current clinical practice guideline for nutrition care in chronic kidney disease by registered dietitian nutritionists (RDNs) and (2) evaluate impact of a comprehensive guideline training on RDN practice.

We evaluated implementation of recommendations for subjective global assessment and intake of dietary protein, energy, phosphorus, and oral nutrition supplements (ONS). RDNs were randomized to receive standard knowledge-based guideline training or comprehensive training (standard training plus implementation training). Outcomes included congruence (consistency) between documented practice and guideline recommendations and RDN-reported guideline acceptability, adoption, and adaptation. Outcomes were descriptively analyzed, and odds of congruent care were compared by training group using multilevel logistic regression.

Twenty-five RDNs from 28 US clinics documented nutrition care for 565 hemodialysis patients over 1,175 visits. Provided care was congruent or fully congruent with the guideline for almost all identified visits covering intake of protein (100% of visits), phosphorus (95%), and energy (95%) and most visits discussing ONS (69%). Most subjective global assessment components were rarely documented (<7% of visits) except for weight/weight change. Top RDN-reported acceptability factors were potential for positive impact on patients, strength of the evidence-base, and alignment with their current practice and skillsets. They noted more leadership level support was required to fully implement some recommendations (e.g., ONS). The comprehensive training did not improve odds of congruent care compared with standard training.

RDN documented practice was congruent with most selected guideline recommendations. A multilevel approach may improve implementation of recommendations.