Nutritional Supplementation in Adult
Patients on Hemodialysis
Noël Cano, MD, PhD
At the beginning of the 1980s, nutritional status appeared as a key element of quality of life, health care
requirements, and survival during chronic renal failure. In patients on dialysis, malnutrition is a major determinant
of survival, and its management appears to be a key element in terms of outcome. Recommendations for the
nutritional management of patients on hemodialysis have been elaborated by the National Kidney Foundation (NKF)
and the European Society of Parenteral and Enteral Nutrition (ESPEN).
© 2007 by the National Kidney Foundation, Inc.
Nutritional Requirements
Recommended protein intake is 1.2 to 1.4 g/kg/
day, calculated for ideal body weight. High bio-
logical value proteins should be higher than
50%.1,2 Because no substantial clinical data sup-
port the use of specific amino acid formulas,
standard protein supply is worthy. The required
energy intake is 35 kcal/kg/day,1,2 except in
patients older than 60 years, in whom energy
intake of 30 kcal/kg/day is recommended by the
National Kidney Foundation (NKF).1 Caloric
supply should take into account abnormalities of
glucose and fat metabolism. Fat should account
for 30% to 40% of the energy supply. The addi-
tion of carnitine (0.5 to 1 g daily) has been
recommended when plasma free carnitine is re-
duced. Because of dialysis-induced losses, water-
soluble vitamins should be supplied: folic acid
(1 mg/day), pyridoxin (10 to 20 mg/day), and
vitamin C (30 to 60 mg/day).2 Vitamin D should
be given in accordance with calcium and phos-
phorus monitoring. In depleted patients, zinc (15
mg/day) and selenium (50 to 70 ␮g/day) supple-
mentation may be useful.
Service d’Hépatogastroenterologie et Nutrition, Clinique Rési-
dence du Parc, Marseille, France.
Address reprint requests to Noël Cano, MD, PhD, Centre
Hospitalier Prive, Service d’Hépatogasroenterologie et Nutrition,
Residence du Parc, 13010 Marseille, France. E-mail: njm.cano@
numericable.fr
© 2007 by the National Kidney Foundation, Inc.
1051-2276/07/1701-0020$32.00/0
doi:10.1053/j.jrn.2006.10.018
Journal of Renal Nutrition, Vol 17, No 1 ( January), 2007: pp 103-105
Nutritional Supplementation
Nutritional support includes nutritional coun-
seling, oral supplementation, intradialytic paren-
teral nutrition (IDPN), and enteral nutrition.
Oral supplementation and IDPN improve pro-
tein metabolism during dialysis.3,4 Nutritional
counseling, the first step in nutritional support,
was reported to improve nutritional status,5 high-
lighting the importance of regular (twice yearly)
assessment and adjustment of spontaneous in-
takes. Numerous studies have addressed the nu-
tritional effects of various oral supplements in
patients on hemodialysis (HD); isolated adminis-
tration of amino acids, protein, or glucose poly-
mers, or associated protein and energy supplies,
provides 200 to 600 kcal and 8 to 25 g protein. A
systematic review with meta-analysis addressing
protein– calorie oral and enteral supplements
showed an increase in serum albumin of 2.3
g/L (95% confidence interval, 0.37 to 4.18) in
maintenance HD patients.6 In patients with
documented malnutrition, 6 controlled studies
showed improvement in nutritional parameters
during nutritional supplementation.7–12 An in-
crease in Karnofsky scale score12 and spontane-
ous feeding were observed during oral supple-
mentation.11 The main limitation of oral
supplementation may be patient compliance. In
the French Intradialytic Nutrition Evaluation
study (FineS), compliance with standard oral
supplements was greater than 60% after 1 year,
and sustained improvement in serum albumin
and prealbumin was observed.13
IDPN is a cyclic parenteral type of nutrition
that is given 3 times weekly through the venous
103
104 NOËL CANO
way of the dialysis line. IDPN given during
4-hour dialysis sessions provides up to 800 to
1,200 kcal in the form of glucose and fat emulsion
and 30 to 60 g of protein. More than 30 studies,
including 5 prospective, randomized, controlled
trials, addressed the nutritional effects of
IDPN.14 –18 Although these studies differed ac-
cording to nutritional supply, number of patients,
length of treatment, and tested nutritional param-
eters, they showed improvement in tested nutri-
tional variables. In patients with low serum albu-
min, retrospective studies reported that IDPN
may improve survival.19 In a prospective, ran-
domized, intent-to-treat trial, FineS study inves-
tigators evaluated the effects of 1-year IDPN,
given in addition to oral supplements, in 182
malnourished HD patients. The addition of
IDPN to oral supplements did not improve mor-
tality, hospitalization, disability, or nutritional sta-
tus. Independent from the means of nutrition
used, nutritional support induced nutritional im-
provement, which, in turn, significantly influ-
enced survival. Particularly, the increase by 30
mg/L in serum prealbumin during the first 3
months of supplementation was associated with a
50% decrease in 2-year mortality.13
Both oral supplementation and IDPN can pro-
vide only the equivalent of 7 to 8 kcal/kg/day
and 0.3 to 0.4 g protein/kg/day. When malnu-
trition is associated with spontaneous intake
lower than 0.8 g protein and 20 kcal/kg/day,
daily nutritional support is needed to ensure rec-
ommended nutritional intake. In these condi-
tions, enteral nutrition should be preferred to
Table 1. Management of Malnutrition in Patients on Maintenance Hemodialysis
Detection and treatment of any cause of anorexia or catabolism:
Correction of inadequate diet
Correction of inadequate dialysis delivery
Treatment of anemia
Detection and treatment of depression
Detection and treatment of associated gastrointestinal disorders
Nutritional monitoring:
Diet record
BMI, nPNA, predialysis creatinine
Serum albumin and prealbumin
Mild or moderate malnutrition:
Inadequate diet without criteria of severe malnutrition
Severe malnutrition: Serum albumin
Serum albumin ⬍35 g/L, prealbumin ⬍300 mg/L, nPNA ⬍1 g/L
If spontaneous intake ⬎20 kcal/kg/day
If spontaneous intake ⬍20 kcal/kg/day
BMI, body mass index; nPNA, normalized protein equivalent of nitrogen appearance; IDPN, intradialytic parenteral
nutrition.
parenteral nutrition20 Only a few studies have
addressed the use of enteral nutrition in adult
patients on dialysis. Enteral nutrition is most often
used when oral supplementation and/or IDPN is
not able to satisfy nutritional requirements, as in
severe anorexia or with swallowing troubles
caused by neurologic or head and neck disease.21
Enteral nutrition is safe and can meet the total
nutritional needs of patients on dialysis.22 When
enteral nutrition lasts for 1 month, a gastrostomy
is usually needed—most often, perendoscopic
gastrostomy.
Nutritional Management of
Patients on Hemodialysis:
Perspectives
Because of the influence of malnutrition on
outcomes and on the ability of nutritional support
to improve survival,13 nutritional monitoring is
necessary in maintenance HD patients (Table 1).
Severe malnutrition, which compromises the
middle-term prognosis, can be detected by se-
rum albumin ⬍35 g/L, prealbumin ⬍300
mg/L, and normalized protein equivalent of
nitrogen appearance (nPNA) ⬍1 g/kg/day.
Table 1 proposes a schema for the management
of malnutrition.
Several perspectives have developed regarding
the treatment of malnutrition in dialysis. Daily
dialysis, known to induce liberalization of ali-
mentation and improved nutritional status,
should be assessed as a therapy for malnutrition in
selected patients.23 Specific amino acid mixtures,
Intervals:
6–12 months
1 month
1–3 months
Proposed treatment:
Diet counseling and oral supplements
Proposed treatment:
Oral supplements, IDPN, if poor compliance
Enteral nutrition
 NUTRITIONAL SUPPLEMENTATION IN HEMODIALYSIS
designed to improve the yield of protein synthe-
sis, must be studied in a controlled fashion. Im-
provement in protein metabolism was noted in
pilot studies with pentoxifylline, recombinant
growth hormone, and insulin-like growth fac-
tor-I in adult patients on dialysis.24 –26 In a con-
trolled, randomized, double-blind study, admin-
istration of nandrolone decanoate was associated
with increased muscle mass, as assessed by predi-
alysis creatinine and dual-energy x-ray absorpti-
ometry (DEXA), and improved muscle perfor-
mance.27 Prolonged nutritional studies are
required to establish the beneficial effects and
tolerance of these therapies. Pupim et al28 showed
that exercise combined with IDPN, as compared
with IDPN alone, induced a 2-fold increase in
forearm muscle essential amino acid uptake and
net muscle protein accretion. The data suggest
that a multidisciplinary approach that combines
nutritional support, exercise, and anabolic agents
should be tested with the goal of determining the
optimal treatment approach for malnutrition dur-
ing dialysis.
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