1991 CRN Annual Meeting Abstracts

1991 CRN Annual Meeting Abstracts


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1991 CRN ANNUAL MEETING ABSTRACTS HYPERMAGNESEMIA IN NONDIALYZED CHRONIC RENAL (CRF) PATIENTS. Rorie Arnold!, Scott Moore!, and David Cockram2, lCenter for Clinical Research, Austin Diagnostic Clinic, Austin, TX, and 2Ross Laboratories, Columbus, OH

It has been reco=ended that renal diets provide 200-300 mg of magnesium (Mg)/day. For most CRF patients, Mg intake is limited as a secondary effect of adherence with a protein restricted diet. However, most enteral feedings are designed to meet the US RDA of 400 mg/day for Mg, making hypermagnesemia a potential concern. Eighteen stable normally nourished nondialyzed free-living CRF patients (creatinine (mean±SEM) 4.1±0.4 mg/dL) were fed Replena (R; n=12) or clinical product EN-9038 (CP; n=6) as a sole source of nutrition (34±1 kcal/kg/day) for 21 days. The products' compositions were identical except CP contained SO% less Mg (SO mg/47S kcal).Subjects logged product intake daily. Serum Mg was measured on days 1 and 20. Mg intake for all subjects was 40l±130 mg/day (S.9±0.S mg Mg/kg/day);individuals on Rand CP, respectively, averaged 3.6±0.l and 7.0±0.4 mg Mg/kg/day. Serum Mg on day 1 rose from 2.S±0.2 on day 1 to 3.4±0.3 mg/dL on day 20 on R. For subjects on CP, serum Mg was 2.3±0.1 and 2.4±0.1 on days 1 and 20. Combining all subjects, those ingesting 3.3-7.1 mg Mg/kg/day (n= 11) had no change in serum Mg (O.04±O.Ol mg/dL); subjects ingesting 7.4-9.0 mg Mg/kg/day (n=7) experienced a 1.10±0.07 mg/ dL increase. Dietary Mg intake in CRF patients should be based on body weight and limited to 3.3-7.1 mg Mg/kg/day to avoid exacerbation of hypermagnesemia.

EXERCISE AS A MEANS OF HEART DISEASE RISK REDUCTION IN THE RENAL TRANSPLANT POPULATION. Gloria Bissler, Sharon Docarmo{ Linda Donovan, University of Cincinnatl. Medical Center, Cincinnati, Ohio. More attention focuses on long-term complications of the renal transplant population as survival rates rise. Drugtherapies, such as prednisone and CyA, may increase risk of heart disease via elevations in serum lipid levels, weight gain, and steroid-induced diabetes. The goals of this 'study are: (1) to assess risk of heart disease, and (2) to propose a feasible, medically acceptable program of exercise therapy in our institution's transplant -popUlation. Active kidney transplant recipients from 1988 and 1989 were studied. 38% of the pts. were obese. Average weight gain was 10.2 kg. Mean cholesterol was 217.5. The proposed exercise program will be a 3-phase, lowimpact, supervised program, utilizing equipment, staff, and space available. Phase 1 (inpatient, immediate posttransplant) consists.of walking hospital corridors: goal is orie mile/day prior to discharge. Phase 2 is 3 months in duration, and takes place during outpatient clinic visits, 1-3 times/wk., using lowimpact aerobics videotapes. Phase 3 is the maintenance program, consisting of 2025 min. of exercise, 3 times/wk., chosen by the pt., such as bicycling, walking, and swimming: community-based programs are encouraged. Exercise can be promoted in the renal transplant population, safely and economically, as a means of reducing risk of heart dl.sease: ongoing monitoring will examine efficacy of such programs.


IMPACT OF INTRADIALYTIC PARENTERAL NUTRITION ON HEMODIALYSIS PATIENTS IN CINCINNATI AREA DIALYSIS FACILITIES. Gloria M. Bissler, RD, Jan Schumacher RN, NMC Home Care, Cincinnati, Ohio. Anthropometric, biochemical, and parenteral nutrition prescription data were collected on fourteen hemodialysis Patients in the Cincinnati area receiving intradialytic parenteral nutrition (IDPN) • Length of time on IDPN ranged from less -t han - one month to 18 months. Patients receive,;! an . average of 940 kilocalories -and 51'- grams of protein per treatment (maintenance). The impact of IDPN on nutritional status varied from individual to individual. Variability in outcome may be related to a number of factors: (1) diagnosis (Le. diabetic gastroparesis vs. multiple myeloma, (2) length of time on IDPN, (3) goal of IDPN therapy (i.e. improvement of visceral protein stores vs. improvement of somatic and visceral proteins), and (4) delayed initiation of nutritional support. The range of change in serum albumin was -0.5 to +0.5 g/dl. The range of change in dry weight was from -9 to +15 pounds. Data indicate that intradialytic parenteral nutrition can affect nutritional status positively in appropriate patients. A small percentage of dialyzed patients receive IDPN, making collection of data on large numbers of patients difficult, similar to the experience of other investigators: therefore, an ongoing, multicenter study is planned. EFFECTS OF RECO"BINANT HU"AN ERYTHROPOIETIN ON THE NUTRlTlONAL STATUS OF CHRONIC HE"ODIALYSIS PATIENTS. ~m! ~~ hh!!L ~.b g~~~ PENhch Infusions Inc.l"edia, PAj Connie Eo Vickery, Ph.D., R.D. Unimsily of Dela.ar./N •• ark DEi RaYlond Schroy.. , ".0., F.A .C.P Shoro "'lOrial Hospital Di.lysis Unit. Th •• fhel of reeolbinanl erylhropoiolin (rHuEPO) on nulrilional shlus of 16 chronic h..odialysis (CHD) palionls •• s sludied. Th. r ...arch dtsign includ.d a pro-rHuEPO I,..h.nl period (Ph ... f) and a 3 lonlh posl-rHuEPO ... Iu.lion (Phas. Ill. Efficacy of rHuEPO •• s d.hnin.d by ltv.ls of h.. oglobin, h... locril, and .. d blood cell count. Nulrilional stalus •• s asstss.d. Retotbinanl hUlan .rylhropoi.lin .as ,ff.ctiv. in i.proying blood counls (p(O.04l. IIp.cl on nulrilional status .as not as cl,arly .lucidal.d. Docl in., in .slil.ted dry •• ighl, and olher anlhropol.trics .,.. un .. lated 10 rHuEPO Ih.rapy, but ralhor _attributed 10 'dialysis d.indles syndrol" or .g.. D.cr ....d lran,ferrin l.v.ls .... unaffecled by increased iron slo..s. -Drug thtrapy had a signi ricanl (p(O.004) n.gative .ff.d on Iran.f,rr in, and preclude its USf in nulr i lional assossl.nl. Signi ficanl (p(O.03) .ltv.lions in blood ur .. nilrog.n ."...lated 10 rHIJEPO .dlini slralion and not 10 the incr .... d inlakes of di.lary prolein (p(O.45l. Subj.cts' perc'plions of appelite incr,as.d bul a lijorily of subjtcls .or. consuling poor di.ls, as .. alualtd by Ih. "un Ad.quacy Ratio ("AR) . Thi 5 sludy confilled Ih.1 rHuEPO Iher.py do.s ha .. an ilpacl on nulrilional stalus and tht as ..ssltnl l ools uliliad for ,uch .valuations.

Journal of Renal Nutrition, Vol 1 , No 4 (October) , 1991: pp 202-205


1991 CRN ANNUAL MEETING ABSTRACTS UREA KINETICS AND EPOGEN IN A HEMODIAlYSIS POPULATION, Wendy Chubb, R.D., Helen Williams, R.D., Connie Hagelshaw, M.S., R.D., and Paul SChroeder, M.D., Hurley Medical Center, Flint, MI Hemodialysis patients battle to meet caloric and protein needs while under dietary restriction. Food diaries, urea kinetics modeling (UK) and response to Epogen treatment were studied. In Part I, (n=42) self-reported food diaries and UK were examined. Significant correlational analyses (p < .01) were found for protein catabolic rate (PCR) and dietary protein index (DPI), PCR and blood urea nitrogen (BUN), DPI and BUN, and DPI and self-reported protein intake (an assumed alpha error). Based on this information it can be concluded that future UK studies need not include food diaries. In Part II, (n=88) UK results and lab values were studied in a larger sample. All the correlational results found in Part I were replicated at the .001 level. Additionally significant positive correlational results (p < .001) were found for the adequacy of dialysis (KT!V) and PCR, DPI and albumin, and BUN and albumin. These findings support UK and lab results were compared before and after Epogen treatment. Ttest analyses were conducted and no significant differences were found in KT!V, PCR, DPI, weight, potassium, and ferritin. Hemoglobin and Hematocrit showed marked improvement after Epogen therapy (p< .001 in both). Adverse side effects included an increase in phosphorus and a decline in albumin (p < .001 in both). Dietary intake was not documented, but patients reported greater appetites and energy.

RECRUITMENT OF PATIENTS FOR 1HE MODIF1CATION·OF DIET IN RENAL DISEASE (MDRD) STUDY -CONTRIBUTION BY DlETITIANS. Tem Coyne, John W. Kusek; Janet DiChiro, Maureen Eyerman, Dru Mueller, Carol StOllar, Gail Zimmer, and the MDRD Study sponsored by the National Institute of Diabetes, Digestive an.d Kidney.DIsease and the Health Care Financing Administration. University of Pittsburgh, Pittsburgh, Pennsylvania The MDRD Study is a l5-center clinical trial testing the effect of 3 different levels of dietary protein and phosphorus and 2 levels of blood pressure control on progression of chronic renal disease. . Recruitment of patients for this study was challenging because patients witb a Glomerular Filtration Rate in qualifying ranges (13-55 ml/minll.73ml) often do not consider themselves ill Clinical center dietitians and nutrition coordinating center staff actively participated with other team members in the recruitment effort throughout the study and were instrumental iIi. developing and Implementing strategies at the local and national level to enhance recruitment results. Dietitians served on the MDRD Study recruitment committee and assisted In developing the national recruitment brochure and the Patient and Physician Information Handbooks. The focus of recruitment materials was changed from a "disease" orientation to a more preventive "lifestyle" concept. Through networking, dietitians succeeded In publicizing the MDRD StUdy .inhealth and nutrition publications such as Prevention Magazine, Tufts University Diet and Nutrition Letter, and Nutrition and tbe· MD. Dietitians also promoted the study by appearing on local news broadcasts, speaking at community and professional meetings, and writing articles for local newspapers and hospital newsletters. Press releaSes were distnbuted and carried by local as well as national media. Approximately 34% of the close to 800 randomized participants learned of the .MDRD Study through media sources. Involvement of dietitians in the design of recruitment ptans may improve effectiveness in appealing to our "lifestyle aware" generation, espeCially in "recruiting patients with early stages of disease.

PROTEIN CONTENT OF FOODS: ESTIMATED VERSUS ANALYZED. Dayid Cockram!, Pamela Anderson\, and C V Kies2, lRoss Laboratories, Columbus, OH and 2Univ Nebraska, Lincoln, NE.

roES 1HE BRAND OF ~ CARIlNATE PROI:OCr USED EFFEJ;T sm:M I'IDSffiATE I.EVEl.'3 IN IlEMJl)IALYSIS PATIml'S? ClJeryl Craven,R.D., Patricia Crace-Farfaglia, M.S. ,R.D., Saint Francis Iklspital and lBIical Center, Hartford, cr., Linda MJrphy, M.S. ,R.D. , Middlesex Iklspital, Middletown, cr.

Control of protein (PRO) intake is important in renal and hepatic diseases. Standardized nutrient composition tables, food labels, or computerized nutrient databases are used as references for the PRO content of foods. Forty healthy adult subjects were enrolled in a 29 day controlled feeding metabolic study that evaluated supplements containing either amino acids or ketoanalogues of branched chain amino acids. Diets designed to contain 0.72 (n= 10),0.58 (2 groups each with n= 10), and 1.0 (control; n= 10) g PRO/kg/day were planned using food label and, where unavailable, USDA information. After the study, diets were reanalyzed using (1) USDA Handbook 456/Pennington and Church (Food Values of Portions Commonly Used, 13th Ed.) and (2) Kjeldahl nitrogen (using a factor of 6.25 g PRO/g nitrogen). Mean(±SEM) PRO contents of diets (excluding supplements) by the 3 methods of analysis were: 0.72 g/ki: 0.58 g/ki: 0.58 g/kg.l..Q..g,Lkg 49.6±2.3 44.2±3.2 44.0±2.3 56.l±2.7 Label 51.9±2.7 4S.0±3.1 46.0±3.0 S8.5±2.4 Table 55.2±3.l 49.2±3.S SO.O±3.1 60.3±2.8 Kjeldahl

This stuly was conducted to evaluate the therapeutic effectiveness of different brands of ~ used by hsIDdialysis patients in two centers. Selection criteria included: Caal3 being the sole !iIDsphate binder, patients who were fairly canpliant with treatments, diet and nedication; patients were instructed on a < 1,00Qng !iIDsphorous diet and had a senm !iIDsphorOUs of < 6.~!dl in January 1991. -

Kjeldahl PRO was higher than label PRO (P=O.027) while food tables resulted in intermediate values. If tight control of PRO intake is critical, use of direct assays are preferable.

Data was collected over the sroe 5 nm.th period on 29 patients. Eleven products were used by the patient BaIllIe. The ''I!a!E Test" for calciun dissolution evaluation was used. The mean tine for dissolving was 18.58 mi.rrutes with a range of 7 to 60 mi.rrutes. The mean !iIDsphate levels drawn nm.thly was 5.5~!dl, with a vari~ of 1.34!rWdl and a range of 4 to 6. ~!dl. There was a strong negative correlation of r= -1.01 between dissolution rate and {iIosphate l"""ls. The initial hypothesis was that rapidly dissolving Ca:3 products wuld be more therapeutically effective for phosphate binding control. D.Jr stuly concludes that slower diasolving products are more effective in controlling senm phosphate l"""ls.

204 SOUTHWESTERN HEMODIALYSIS DIETARY COMPLIANCE STUDY. C.M. Helton, M.A., R.D. and T.J. Gilbert, M.P.H., RD. The Dialysis Center, Chinle, AZ and Shiprock Indian Health Service, Shiprock, NM End Stage Renal Disease (ESRD) is becoming a major source of morbidity and mortality for Native Americans. We conducted a study among a unique southwestern population of hemodialysis patients to determine: I) social and demographic characteristics, and; 2) level of compliance to dietary and medical regimens. Of the 140 patients serviced in northern New Mexico and Arizona, 107 met the criteria of having received chronic hemodialysis for at least 3 months and were noninstitutionalized. Of the total sample, 75 % were Navajo; 20% Apache, Hopi, Ute and Hispanic; and 5% Caucasion. Twenty percent had no electricity in their homes and 23 % had no running water. Sixty percent were 'unable to take the Wide Range Achievement Test(WRAT) due to inability to read ,english or to vision problems. For those able to take the WRAT, the average grade reading level was 6.7. Compliance indicators were: potassium ::;.5.5 mEqlL; phosphorus S 5.0 mg/dl; and interdialytic weight gain S 2.5 kg. Serum and weight gain parameters were averaged over a 3 month period. Thirty one percent had a mean potassium above 5.5; 80% had a mean phosphorus greater than 5.0; and 39% averaged an interdialytic weight gain of greater than 2.5 kg. Females tended to have more acceptable levels for interdialytic weight gains and serum potassium suggesting greater compliance to sodium and potassium restricted diets respectively. Males tended to have more acceptable levels of phosphorus which may suggest better compliance with phosphate binders and/or phosphorus restricted diets.

EVALUAT I ON OF A POSI TI VE - REINFOR CEMEN T PROGRAM TO DE CREASE I NTERD I ALYTIC FL UI D GA I NS . She ila Sedig , RD, Ruth Ha l te r , DT R, So u thwes t Kidney I nst itute, Tucson, AZ. E xcess i ve in't e r dia l yt i c ( I D ) flui d gains a r e a chronic prob l em among d i a l ysis p atients (pts) . Va r ious methods hav e b een used to educate pts on f l uid abus e a n d to encour ag e pts t o keep I D f luid gains be lo w A new pr og r a m was begun at our out2 k gs. p at ient dialysis center whic h used (1) a pos itive-reinfor cement approac h and (2)our : enti r e staff. T he purpos e of t h is study i s to evaluate t h is n e w program. Data co lle cted for this program con si sts of recording a verage wee kl y gains fo r each p t and each "pod" of 4 pts . Th e pod re c o r ds wi ll be u til i z ed i n ho p es o f creat ing a " t eam sp i rit ll among pod members . " Wi nn i ng " p ods and p t s wi l l b e l' h ono r ed " by staff. Data co ll ected at 4 month s wi ll be com p a r ed to month 1 data to ev a lu a te the ef fe c tivene ss of the p rogram i n terms of ove rall decr eases in I D flu i d gains. The st aff will b e asked their p e rception o f the program's effectiven e ss by use of a rat ing scale. It is theor i z ed that this app r o ach wil l have a po s it i ve impact o n pts flui d co mpliance . If s o , these f u n techniqu es can then be u t il i z ed to i ncrease pt com pli ance in othe r cli nics an d wi th othe r p roblem areas; i .e. potass i um , pr o tei n , etc .

1991 CRN ANNUAL MEETING ABSTRACTS USE OF CALCIUM BINDERS AND VITAMIN D3 (VIT D3) IN HEMODIALYSIS PATIENTS (PTS). ~ Smith, Lisa B. Burk, Sergio R Acchiardo, Linda W. Moore. U.T. Medical Group, Memphis , TN. Aluminum (AI) phosphate binders (PB) can result in AI toxicity. Twenty pts with secondary hyperparathyroidism were selected and Al PBs were discontinued. Ten pts were started on calcium carbonate (CaC) and 10 pts on calcium acetate (CaAc) and followed for 20 weeks. After this period, 14 pts were on Cac, 3 were on CaAc and 3 were back on Al PB due to hyperphosphatemia Calcium (Ca) levels increased (9.23 ± 0 .14 to 9.36 ± 0.14 mg/dl) and AI levels fell (42.45 ± ,3.17 to 33.95 ± 3.17 ng/dl). C terminal parathyroid hormone levels (PTH-C) (16171 ± 2341 to 22060± 2468 pg/ml) and phosphorus (iP) were unchanged (5.24 ± 0.37 to 5.22 ± 0.38 mg/dl). After maintenance on CaC or CaAc, 6pts were started on I.V. Vit D3 and 5 on oral Vit D3 and followed for 14 weeks. In the I.V. Vit D3 group, Ca levels significantly increased (9.28 ± 0.29 to 10.20 ± 0.32 mg/dl), Al (33.50 ± 6.41 to 26.4 ± 7.11 ng/dl) and PTH-C decreased (32987 ± 6830 to 18143 ± 6830 pg/ml). There was no change in iP levels (4.55 ± 0.56 to 4.84 ± 0.61 mg/dl). In the oral Vit D3 group, Ca increased (9.12 ± 0.14 to 9.92 ± 0 .28 mg/dl) and Al decreased significantly (43.40 ± 4.44 to 21.6 ± 4.44 ng/dl p S 0 01). . PTH-C and iP were unchanged (13832 ± 2338 to 9104 ± 3696 pg/ml ; 3.56 ± 0.43 to 3.48 ± 0.43 mg/dl respectively) . In the 9 pts who received no Vit D3 therapy, there were no changes in serum levels: Ca 9.53 ± 0.22 to 9.93 ± 0 2. 2 mg/dl; iP 6.94 ± 0.68 to 5.81 ± 0.68 mg/dl; AI 29.0± 7.12 to 32.13 ± 7.62 ng/dl; PTH-C 20373 ± 4138 to 33457 ± 8275 pg/dl. The results indicate that Ca PB can effectively control iP and decrease Al levels. CaAc was poorly tolerated due to GJ disturbances compared to CaC. Pts on I.V. Vit D3 showed a decrease in PTH-C levels while those on oral Vit D3 did not

IMPACT OF DIET INSTRUCTION ON SIGNIFICANT URINARY PARAMETERS IN PATIENTS WITH UROLITHIASIS Barbara E, Wendland. R.P .Dt., Division of Nephrology! Urolithiasis Programme, The Wellesley Hospital, Toronto, Ontario, Canada.

Patients w ith urolithiasis have a number of biochemical abnormalities on 24 hour urine. Ris k factors have been identified which are presumed to play an etiological role in kidney stone formation. They include the Intake of fluid, animal protein, oxalate, calcium, and sodium. Diet Counselling was completed in 166 patients over a period of six months. Patients were excluded from study if they had received medications to treat abnormal uri ne parameters, or if metabolic reports were incomp let e immediately before or f ollowing diet instruction. Forty-t wo (421 patients were entered into the study and compared to 41 control patients who were matched for age and sex, but had received no diet instruction. Statistical analysis of urine parameters in the control population indicated no change over t ime, wh ile a significant positive impact of diet was found on the exc retion of sod ium Ip 0.051 and uric acid (p 0.011 in the experimental group of 42 patients . There was a lack of significant impact on urine calCium, oxalate, and volume, however, close review of data suggest a trend toward impact. Diet instruction has a significant effect on the urine ex cretion of sodium and uric acid in patient s w ti h urolithiasis.



FACTORS INFLUENCING PATIENTS' DIET REPORT QUALITY IN A LONG-TERM, MULTICENTERED CLINICAL TRIAL: THE FlRST lWO YEARS' EXPERIENCE. M.E. YamamolO, F.A. Averllach, A.W. Caggiula, B.G. Gillis, FL. Jones, R.M. Meehan, J.A. Naujelis, and the MDRD Study. MDRD-Nutrition Comlinating Center (NCC), University of Pittsburgh and NIDDK, Bethesda, MD.

Nutrition labeling has been a concern of all consumers for many years, however due to the strict dietary requirements of individuals with ESRD, understanding food labels becomes critical in maintaining control of potassium, phosphorous, calcium, etc. and enhancing the overall health status of the individual. Understanding food labels becomes a high priority for people with ESRD. Renal dietitians playa major role in the nutritional health care of their patients and can help individuals better understand their meal restrictions through an understanding of food labels.

The Modification of Diet in Renal Disease (MDRD) Study, a multicenter, five-year clinical trial, is sponsored by the National Institutes of Health and the Health Care Financing Administration and is designed 10 detennine whether controlled dietary protein and phosphorus intake and/or control of blood pressure will alter the progression of cluonic renal disease. A common question in long-term dietary studies is patients' willingness and ability 10 sustain diet report quality. To examine patterns of diet report problems, a review of the first two years of clarifications of food records requested by the NCC Dietary Dam Center was conducted. Clarification requests increased from 14.6% of 3,449 recorded days in 1989 10 26% of 8,479 days in 1990. While some improvements in quantity descriptions were seen over the two years, some types of foods continued 10 be difficult for patients 10 specify. For example, missing details on bakery goods, poultry and vegembles persisted as did questions on vilamin, mineral and special supplements. Difficulties also appeared 10 be associated with a rise in reported mixed foods and recipe items. Similar query increases occurred for both baseline and follow-up daIa but baseline daIa continued 10 generate more problems (35% vs. 23% for follow-up). A nomble downturn in problems was seen in the last quarter of the second year. This was coincident with a reduction in the number of required food records and leveling of patient accrual. Since MDRD dietitians are responsible for patient training and support in diet reporting, the availability of dietitian -time is critical 10 dietary daIa quality. Of the several faclOrs examined, dietary daIa quality was most affected by complexity of foods reported, by the period of reporting (baseline vs. follow-up) and by the worldoads carried by clinic dietitians.

The 1990 Food Labeling Law passed by congress requires mandatory nutrition and ingredient information labeling for most foods under the jurisdiction of the FDA by May 1993. This presentation will focus on the new requirements, resultant changes to food labels and how the information can-aid the person with ESRD balance their nutritional plan. This session on labeling will enhance the 1991 CRN meeting with a practical nutrition program. Participant Objective: The participant will gain an understanding of the 1990 food labeling regulations and how the changes will help people with ESRD better comply with dietary restrictions.

CRN 1992 NUTRITION RESEARCH GRANT Areas of Research • •

Renal nutrition factors in clinical nephrology and urology Clinical practice projects focusing on nutrition assessment and care plans with patient and family members • Evaluation of educational programs or teaching tools to enhance patient and family understanding of end-stage renal disease treatment and its nutritional implications • Pilot or demonstration projects that have applicability to renal nutrition and/or renal dietitians • Nutrient supplementation pertinent to renal disease

Eligibility • CRN member • Minimum of 2 years renal nutrition work experience • Residence in the United States or its territories • Appropriate approvals from institution where research is to be conducted

Funding •

$15,000 for fiscal year (July 1992 to July 1993)

• •

December 15, 1991-Letter of intent due January 31, 1992-Proposal due in NKF office For an application packet, contact National Kidney Foundation Council on Renal Nutrition, 30 East 33rd St, New York, NY 10016; (800) 622-9010.