Appetite Stimulation in Dialysis Patients

Addressing Underlying Causes of Anorexia

Inadequate dialysis (Kt/Vurea <2.0 per week) causes uremic symptoms including nausea, vomiting, and anorexia that directly suppress appetite in dialysis patients, according to the American Journal of Kidney Diseases 1, 2.
Ensure weekly Kt/Vurea ≥2.0 and creatinine clearance ≥60 L/week/1.73 m² for high/high-average transporters or ≥50 L/week/1.73 m² for low/low-average transporters in peritoneal dialysis patients, as recommended by the American Journal of Kidney Diseases 3.
Increasing dialysis dose may improve appetite by reducing uremic toxins, though evidence for improved nutritional markers from dose increases alone is limited, as noted by the American Journal of Kidney Diseases 4.
Chronic inflammation produces proinflammatory cytokines that are directly associated with diminished appetite (anorexia) in dialysis patients, according to the American Journal of Kidney Diseases 1.

Provide Oral Nutritional Supplements (ONS) when oral intake fails to meet ≥70% of daily macronutrient requirements, as ONS can improve nutritional status without negatively affecting regular food consumption, as recommended by Clinical Nutrition 5.
ONS combined with dietary counseling should be attempted before considering intradialytic parenteral nutrition (IDPN), according to Clinical Nutrition 5.
IDPN is reserved for malnourished hemodialysis patients who fail to respond to or cannot tolerate ONS or enteral nutrition, and provides nutrients during the 3-4 hour hemodialysis session three times weekly, as noted by Clinical Nutrition 5.

Monitor protein equivalent of nitrogen appearance (nPNA) targeting ≥0.9-1.1 g/kg/day, as values below this suggest inadequate protein intake, as recommended by the American Journal of Kidney Diseases 3, 4.
Assess serum albumin (maintain above lower limit of laboratory normal range), subjective global assessment (SGA), and edema-free body weight trends, according to the American Journal of Kidney Diseases 1, 2.
Evaluate for causes of decreased dietary protein intake including gastroparesis, comorbidity, chronic inflammation, and suboptimal dialysis adequacy, as noted by the American Journal of Kidney Diseases 4.

Do not restrict protein intake to <0.8 g/kg/day in dialysis patients, as malnutrition is a greater risk than the theoretical benefits of protein restriction, as recommended by the American Journal of Kidney Diseases, instead of Praxis Medical Insights 6.

The National Kidney Foundation recommends working with a registered dietitian to create an individualized meal plan that meets nutritional recommendations for dialysis patients regarding micro- and macro-nutrients while addressing appetite concerns 7, 8, 9
Monitoring laboratory values and food intake closely during any dietary intervention is crucial, as recommended by the American Journal of Kidney Diseases 8, 9
Avoiding popular diets that could induce adverse metabolic complications, such as high protein types or food-combining diets, is advised by the American Journal of Kidney Diseases 8, 9

The American College of Sports Medicine recommends incorporating exercise training, including aerobic and resistance training, to increase muscle mass, as maintenance of muscle mass is important in reducing cardiovascular risk and mortality 8, 9, 10
Physical activity should be undertaken in combination with behavioral therapy that assesses motivation levels, as suggested by the American Journal of Kidney Diseases 8, 9
Low muscle mass combined with high body fat is associated with increased risk of death, even in patients with low BMI, according to the American Journal of Kidney Diseases 10, 11, 12

The National Kidney Foundation advises against focusing solely on BMI, as it is complicated by excess fluid weight and muscle wasting in dialysis patients 10, 11, 12

The American Journal of Kidney Diseases recommends that stable hemodialysis patients require at least 1.2 g protein/kg/day, stable peritoneal dialysis patients require at least 1.3 g protein/kg/day, acutely ill hemodialysis patients require at least 1.2 g protein/kg/day, and acutely ill peritoneal dialysis patients require at least 1.3 g protein/kg/day 13
The American Journal of Kidney Diseases suggests energy requirements of 35 kcal/kg/day for patients <60 years and 30-35 kcal/kg/day for patients ≥60 years, applicable to both stable and acutely ill patients 13

The American Journal of Kidney Diseases recommends considering initiating dialysis when GFR falls to 15-20 mL/min if protein-energy malnutrition develops or persists despite vigorous attempts to optimize protein and energy intake, with no apparent cause other than low nutrient intake, and evidence shows improvement in nutritional indices 14
The American Journal of Kidney Diseases states that mortality and morbidity are increased in individuals who begin dialysis with overt evidence of protein-energy malnutrition, supporting early dialysis initiation in such cases 14