Implicit in many of the guidelines in this document is the availability to the patient of an individual with expertise in renal dietetics. Implementation of many of the guidelines concerning nutritional assessment (anthropometry, subjective global assessment, dietary interviews and diaries, and integration of the results of nutritional measurements) and nutritional therapy (developing a plan for nutritional management, counseling the patient and his/her family on appropriate dietary protein and energy intake, monitoring nutrient intake, educational activities, and encouragement to maximize dietary compliance) is best performed by an individual who is trained and experienced in these tasks. Although occasionally a physician, nurse, or other individual may possess the expertise and time to conduct such activities, a registered dietitian, trained and experienced in renal nutrition, usually is best qualified to carry out these tasks. Such an individual not only has undergone all of the training required to become a registered dietitian, including, in many instances, a dietetic internship, but has also received formal or informal training in renal nutrition. Such a person, therefore, is particularly experienced in working with MD patients as well as individuals with CRF.
There appears to be a general sense among renal dietitians, based on experience, that an individual dietitian should be responsible for the care of approximately 100 MD patients but almost certainly no more than 150 patients to provide adequate nutritional services to these individuals.241,242 Because, in many dialysis facilities, the responsibilities of the renal dietitian are expanded beyond the basic care described in these guidelines (eg, monitoring protocols and continuous quality improvement), these facilities should consider a higher ratio of dietitians to patients. Randomized prospective controlled clinical trials have not been conducted to examine whether this is the maximum number of patients at which dietitians are still highly effective.