Nutritional Support for Patients with End-Stage Renal Disease on Hemodialysis

Protein Requirements

The American Journal of Kidney Diseases recommends a target protein intake of 1.2 g/kg/day for stable hemodialysis patients, which equals approximately 54 grams daily for a 45 kg patient 1, 2
In the setting of acute sepsis and critical illness, protein requirements may increase to 1.2-1.5 g/kg/day to offset catabolism and promote tissue repair 3
At least 50% of protein should come from high biological value sources, such as animal proteins, whey, and egg albumin 1, 2

The recommended target energy intake is 30-35 kcal/kg/day for patients ≥60 years old, which translates to 1,350-1,575 kcal/day for a 45 kg patient 2, 3
Adequate energy intake is essential to maintain neutral nitrogen balance and prevent protein from being catabolized for energy 2

Oral nutritional supplements should be the preferred first-line approach in conscious hemodialysis patients with poor oral intake before considering more invasive options 4, 5
ONS should be given 2-3 hours after usual meals to avoid nutritional substitution and suppression of regular food intake 5
Late evening ONS can help reduce overnight catabolism without reducing normal food consumption during the day 5
Intradialytic delivery of ONS has been associated with better compliance and should be considered during thrice-weekly hemodialysis sessions 5

Before considering nutrition support, ensure any potentially reversible conditions affecting appetite have been addressed, such as uremic toxicity, medication side effects, depression, and inadequate dialysis 6
Dietary counseling and education should be the first intervention 1, 6
If oral intake including ONS remains inadequate after counseling, consider tube feeding if medically appropriate 6
If tube feeding is not feasible, intradialytic parenteral nutrition should be considered for malnourished patients who fail to respond to or cannot tolerate ONS 4

Monitor plasma electrolytes and phosphorus closely when initiating nutritional support to prevent refeeding syndrome 3
Serum albumin should be monitored every 1-4 months, with a target of maintaining in the normal range 2
Calculate normalized protein nitrogen appearance, with a target of ≥0.9 g/kg/day 2
Assess for >10% body weight loss over 6 months and maintain BMI >20 kg/m² 2
The dialysis regimen should be regularly monitored and modified to treat any intensification of uremia caused by increased protein intake 6

In the acute septic phase, enteral nutrition should be started at low rates and increased slowly over days to minimize metabolic complications 3
Protein intake of 1.2-1.3 g/kg/day should be maintained regardless of dialysis status to promote protein synthesis and conserve tissue during critical illness 3

Water-soluble B vitamins should be supplemented due to dialytic losses, including folic acid 1 mg/day and pyridoxine 10-20 mg/day 2

Do not restrict protein intake below 1.2 g/kg/day in an attempt to reduce uremia—instead, optimize dialysis adequacy 1, 6
Monitor phosphorus and potassium content carefully when increasing protein intake, as protein-rich foods are major sources of these minerals 1, 5
Avoid overfeeding, particularly with glucose administration exceeding 7 mg/kg/min, which increases risk of hepatic complications 7
Do not delay nutritional intervention, as inadequate intake for even days to 2 weeks can worsen outcomes depending on baseline nutritional status 6