Nutrition in the Elderly with Renal Disease

  • Vincenzo Bellizzi
  • Filippo Aucella
  • Patrizia Calella
  • Philippe Chauveau
  • Lina Johansson
  • Daniel Teta


Elderly patients affected by chronic kidney disease (CKD) and end-stage renal disease (ESRD) are rapidly increasing and represent the major part of renal patients. Elderly renal patients are frail and more susceptible to impair the nutritional status. Conversely, nutritional interventions represent a major part of the comprehensive therapeutic strategies either in predialysis or dialysis phase of the disease, and a safe balance between benefits and harms of nutritional treatment is certainly a challenge.

This chapter first identifies the true elderly renal patient and discusses its nutritional risk and the modalities to monitor the nutritional status and to early discover any nutritional impairment in the elderly renal patients. Thereafter, the major practical nutritional interventions along the course of the renal disease in elderly renal patients are described.



The European Renal Nutrition (ERN) Working Group is an initiative of and supported by the European Renal Association – European Dialysis Transplant Association (ERA-EDTA).


  1. 1.
    Gekle M. Kidney and aging – a narrative review. Exp Gerontol. 2017;87:153–5.CrossRefGoogle Scholar
  2. 2.
    Musso CG, Jauregui JR. How to differentiate renal senescence from chronic kidney disease in clinical practice. Postgrad Med. 2016;128:716–21.CrossRefGoogle Scholar
  3. 3.
    Coresh J, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298:2038–47.CrossRefGoogle Scholar
  4. 4.
    Hommos MS, Glassock RJ, Rule AD. Structural and functional changes in human kidneys with healthy aging. J Am Soc Nephrol. 2017;28:2838–44.CrossRefGoogle Scholar
  5. 5.
    Farrington K, et al. Clinical Practice Guideline Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR). Nephrol Dial Transpl. 2016;31:1–66.CrossRefGoogle Scholar
  6. 6.
    Hallan SI, Gansevoort RT. Moderator’s view: should we diagnose CKD using the ‘one-size fits all’ KDIGO 2012 guideline or do we need a more complex age-specific classification system? Nephrol Dial Transplant. 2014;29:780–2.CrossRefGoogle Scholar
  7. 7.
    Hemmelgarn BR, et al. Relation between kidney function, proteinuria, and adverse outcomes. JAMA – J Am Med Assoc. 2010;303:423–9.CrossRefGoogle Scholar
  8. 8.
    Tonelli M, Riella MC. Chronic kidney disease and the aging population. Kidney Int. 2014;85:487–91.CrossRefGoogle Scholar
  9. 9.
    Stevens PE, Levin A, Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group, M. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013;158:825–30.CrossRefGoogle Scholar
  10. 10.
    Ikizler TA, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int. 2013;84:1096–107.CrossRefGoogle Scholar
  11. 11.
    Johansson L, Hickson M, Brown EA. Influence of psychosocial factors on the energy and protein intake of older people on dialysis. J Ren Nutr. 2013;23:348–55.CrossRefGoogle Scholar
  12. 12.
    Qureshi AR, et al. Factors predicting malnutrition in hemodialysis patients: a cross-sectional study. Kidney Int. 1998;53:773–82.CrossRefGoogle Scholar
  13. 13.
    Cianciaruso B, et al. Nutritional status in the elderly patient with uraemia. Nephrol Dial Transplant. 1995;10(Suppl 6):65–8.CrossRefGoogle Scholar
  14. 14.
    Rambod M, et al. Association of malnutrition-inflammation score with quality of life and mortality in hemodialysis patients: a 5-year prospective cohort study. Am J Kidney Dis. 2009;53:298–309.CrossRefGoogle Scholar
  15. 15.
    de Mutsert R, et al. Subjective global assessment of nutritional status is strongly associated with mortality in chronic dialysis patients. Am J Clin Nutr. 2009;89:787–93.CrossRefGoogle Scholar
  16. 16.
    de Santin FG, Bigogno FG, Dias Rodrigues JC, Cuppari L, Avesani CM. Concurrent and predictive validity of composite methods to assess nutritional status in older adults on hemodialysis. J Ren Nutr. 2016;26:18–25.CrossRefGoogle Scholar
  17. 17.
    Don BR, Kaysen G. Serum albumin: relationship to inflammation and nutrition. Semin Dial. 2004;17:432–7.CrossRefGoogle Scholar
  18. 18.
    Cederholm T, et al. Diagnostic criteria for malnutrition – an ESPEN consensus statement. Clin Nutr. 2015;34:335–40.CrossRefGoogle Scholar
  19. 19.
    Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis. 2001;38:1251–63.CrossRefGoogle Scholar
  20. 20.
    Fouque D, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int. 2008;73:391–8.CrossRefGoogle Scholar
  21. 21.
    Detsky AS, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11:8–13.CrossRefGoogle Scholar
  22. 22.
    Studenski SA, et al. The FNIH sarcopenia project: rationale, study description, conference recommendations, and final estimates. J Gerontol – Ser A Biol Sci Med Sci. 2014;69A:547–58.CrossRefGoogle Scholar
  23. 23.
    Janssen I, Baumgartner RN, Ross R, Rosenberg IH, Roubenoff R. Skeletal muscle cutpoints associated with elevated physical disability risk in older men and women. Am J Epidemiol. 2004;159:413–21.CrossRefGoogle Scholar
  24. 24.
    Lauretani F, et al. Age-associated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. J Appl Physiol. 2003;95:1851–60.CrossRefGoogle Scholar
  25. 25.
    United, U. S. R. D. S. U. 2011 A. D. R. A. of C. K. D. and E.-S. R. D. In the USRDS 2011 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD Natl. Institutes Heal. Natl. Inst. Diabetes Dig. Kidney Dis. Bethesda, MD 1–26. 2011.Google Scholar
  26. 26.
    Danfoss. Annual report 2013. 2013.Google Scholar
  27. 27.
    Kurella Tamura M, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009;361:1539–47.CrossRefGoogle Scholar
  28. 28.
    World Health Organization. World report on ageing and health. 2015. Luxemb. Luxemb 1–260. 2015.Google Scholar
  29. 29.
    Bellizzi V, et al. Low-protein diets for chronic kidney disease patients: the Italian experience. BMC Nephrol. 2016;17:77.CrossRefGoogle Scholar
  30. 30.
    Ko GJ, Obi Y, Tortorici AR, Kalantar-Zadeh K. Dietary protein intake and chronic kidney disease. Curr Opin Clin Nutr Metab Care. 2017;20(1):77–85. Scholar
  31. 31.
    WHO/FAO/UNU Expert Consultation. Protein and amino acid requirements in human nutrition. World Health Organ. Tech. Rep. Ser. 1–265. 2007. ISBN 92 4 120935 6.Google Scholar
  32. 32.
    Young R. Special 1987 McCollum acid metabolism. 1987.Google Scholar
  33. 33.
    Moore LW, et al. The mean dietary protein intake at different stages of chronic kidney disease is higher than current guidelines. Kidney Int. 2013;83:724–32.CrossRefGoogle Scholar
  34. 34.
    Luis D, et al. Renal function associates with energy intake in elderly community-dwelling men. Br J Nutr. 2014;111:2184–9.CrossRefGoogle Scholar
  35. 35.
    Slomowitz LA, Monteon FJ, Grosvenor M, Laidlaw SA, Koppel JD. Effect of energy intake on nutritional status in maintenance hemodialysis patients. Kidney Int. 1989;35:704–11.CrossRefGoogle Scholar
  36. 36.
    Hung KY, et al. Effects of diet intervention on body composition in the elderly with chronic kidney disease. Int J Med Sci. 2017;14:735–40.CrossRefGoogle Scholar
  37. 37.
    Brunori G, et al. Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study. Am J Kidney Dis. 2007;49:569–80.CrossRefGoogle Scholar
  38. 38.
    Bellizzi V, et al. Very low-protein diet plus ketoacids in chronic kidney disease and risk of death during end-stage renal disease: an historical, cohort, controlled study. Nephrol Dial Transplant. 2015;30(1):71–7.CrossRefGoogle Scholar
  39. 39.
    Farrington K, et al. Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR<45 mL/min/1.73 m2): a summary document from the European Renal Best Practice Group. Nephrol Dial Transpl. 2017;32:9–16.CrossRefGoogle Scholar
  40. 40.
    Bellizzi V, et al. A Delphi consensus panel on nutritional therapy in chronic kidney disease. J Nephrol. 2016;29:593–602.CrossRefGoogle Scholar
  41. 41.
    Eckel RH, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American college of cardiology/American heart association task force on practice guidelines. J Am Coll Cardiol. 2014;63:2960–84.CrossRefGoogle Scholar
  42. 42.
    Millen BE, et al. The 2015 dietary guidelines advisory committee scientific report: development and major conclusions. Adv Nutr. 2016;7:438–44.CrossRefGoogle Scholar
  43. 43.
    Kelly JT, et al. Healthy dietary patterns and risk of mortality and ESRD in CKD: a meta-analysis of cohort studies. Clin J Am Soc Nephrol. 2017;12:272–9.CrossRefGoogle Scholar
  44. 44.
    Chauveau P, et al. Mediterranean diet as the diet of choice for patients with chronic kidney disease. Nephrol Dial Transplant. 2017. Scholar
  45. 45.
    Park YMM, et al. Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH) style diet, and metabolic health in U.S. adults. Clin Nutr. 2017;36(5):1301–9.CrossRefGoogle Scholar
  46. 46.
    Martins MCT et al. A new approach to assess lifetime dietary patterns finds lower consumption of animal foods with aging in a longitudinal analysis of a health-oriented adventist population. Nutrients 2017;9.Google Scholar
  47. 47.
    Lin J, Curhan GC. Associations of sugar and artificially sweetened soda with albuminuria and kidney function decline in women. Clin J Am Soc Nephrol. 2011;6:160–6.CrossRefGoogle Scholar
  48. 48.
    Wakasugi M, et al. Association between overall lifestyle changes and the incidence of proteinuria: a population-based, cohort study. Intern Med. 2017;56:1475–84.CrossRefGoogle Scholar
  49. 49.
    Kanda E, Ai M, Kuriyama R, Yoshida M, Shiigai T. Dietary acid intake and kidney disease progression in the elderly. Am J Nephrol. 2014;39:145–52.CrossRefGoogle Scholar
  50. 50.
    Scialla JJ, et al. Higher net acid excretion is associated with a lower risk of kidney disease progression in patients with diabetes. Kidney Int. 2017;91:204–15.CrossRefGoogle Scholar
  51. 51.
    Banerjee T, Liu Y, Crews DC. Dietary patterns and CKD progression. Blood Purif. 2016;41:117–22.CrossRefGoogle Scholar
  52. 52.
    Ntanasi E, et al. Adherence to Mediterranean diet and frailty. J Am Med Dir Assoc. 2017. Scholar
  53. 53.
    Rossi M, et al. Mediterranean diet and glycaemic load in relation to incidence of type 2 diabetes: results from the Greek cohort of the population-based European Prospective Investigation into Cancer and Nutrition (EPIC). Diabetologia. 2013;56:2405–13.CrossRefGoogle Scholar
  54. 54.
    Trichopoulou A, et al. Mediterranean diet and cognitive decline over time in an elderly Mediterranean population. Eur J Nutr. 2015;54:1311–21.CrossRefGoogle Scholar
  55. 55.
    Savanelli MC, et al. Preliminary results demonstrating the impact of Mediterranean diet on bone health. J Transl Med. 2017;15:81.CrossRefGoogle Scholar
  56. 56.
    Johansson L, et al. As we grow old: nutritional considerations for older patients on dialysis. Nephrol Dial Transplant. 2017;32:1127–36.PubMedGoogle Scholar
  57. 57.
    Vanholder R, Lameire N, Annemans L, Van Biesen W. Cost of renal replacement: how to help as many as possible while keeping expenses reasonable? Nephrol Dial Transplant. 2016;31:1251–61.CrossRefGoogle Scholar
  58. 58.
    Mitch WE, Sapir DG. Evaluation of reduced dialysis frequency using nutritional therapy. Kidney Int. 1981;20:122–6.CrossRefGoogle Scholar
  59. 59.
    Locatelli F, Andrulli S, Pontoriero G, Di Filippo S, Bigi MC. Supplemented low-protein diet and once-weekly hemodialysis. Am J Kidney Dis. 1994;24:192–204.CrossRefGoogle Scholar
  60. 60.
    Locatelli F, Andrulli S, Pontoriero G, Di Filippo S, Bigi MC. Integrated diet and dialysis programme. Nephrol Dial Transplant. 1998;13:132–8.CrossRefGoogle Scholar
  61. 61.
    Caria S, Cupisti A, Sau G, Bolasco P. The incremental treatment of ESRD: a low-protein diet combined with weekly hemodialysis may be beneficial for selected patients. BMC Nephrol. 2014;15:172.CrossRefGoogle Scholar
  62. 62.
    Sandrini M, et al. Incremental peritoneal dialysis: a 10 year single-centre experience. J Nephrol. 2016;29:871–9.CrossRefGoogle Scholar
  63. 63.
    Bolasco P, Cupisti A, Locatelli F, Caria S, Kalantar-Zadeh K. Dietary management of incremental transition to dialysis therapy: once-weekly hemodialysis combined with low-protein diet. J Ren Nutr. 2016;26:352–9.CrossRefGoogle Scholar
  64. 64.
    Moss AH, Armistead NC. Improving end-of-life care for ESRD patients: an initiative for professionals. Nephrol News Issues. 2013;27:30–2.PubMedGoogle Scholar
  65. 65.
    Cruz-Jentoft AJ, et al. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39:412–23.CrossRefGoogle Scholar
  66. 66.
    Musso CG, Jauregui JR, Macías Núñez JF. Frailty phenotype and chronic kidney disease: a review of the literature. Int Urol Nephrol. 2015;47:1801–7.CrossRefGoogle Scholar
  67. 67.
    Malafarina V, Uriz-Otano F, Malafarina C, Martinez JA, Zulet MA. Effectiveness of nutritional supplementation on sarcopenia and recovery in hip fracture patients. A multi-centre randomized trial. Maturitas. 2017;101:42–50.CrossRefGoogle Scholar
  68. 68.
    Myint MWW, et al. Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial. Age Ageing. 2013;42:39–45.CrossRefGoogle Scholar
  69. 69.
    Flakoll P, et al. Effect of β-hydroxy-β-methylbutyrate, arginine, and lysine supplementation on strength, functionality, body composition, and protein metabolism in elderly women. Nutrition. 2004;20:445–51.CrossRefGoogle Scholar
  70. 70.
    Baier S, et al. Year-long changes in protein metabolism in elderly men and women supplemented with a nutrition cocktail of β-hydroxy-β-methylbutyrate (HMB), L-arginine, and L-lysine. J Parenter Enter Nutr. 2009;33:71–82.CrossRefGoogle Scholar
  71. 71.
    De Luis DA, Izaola O, Bachiller P, Perez Castrillon J. Effect on quality of life and handgrip strength by dynamometry of an enteral specific suplements with beta-hydroxy-beta-methylbutyrate and vitamin D in elderly patients. Nutr Hosp. 2015;32:202–7.PubMedGoogle Scholar
  72. 72.
    Deutz NE, et al. Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: a randomized clinical trial. Clin Nutr. 2016;35:18–26.CrossRefGoogle Scholar
  73. 73.
    Wu H, et al. Effect of beta-hydroxy-beta-methylbutyrate supplementation on muscle loss in older adults: a systematic review and meta-analysis. Arch Gerontol Geriatr. 2015;61:168–75.CrossRefGoogle Scholar
  74. 74.
    van Zwieten A, et al. Prevalence and patterns of cognitive impairment in adult hemodialysis patients: the COGNITIVE-HD study. Nephrol Dial Transplant. 2017. Scholar
  75. 75.
    Drew DA, et al. Cognitive decline and its risk factors in prevalent hemodialysis patients. Am J Kidney Dis. 2017;69:780–7.CrossRefGoogle Scholar
  76. 76.
    Smith AD, et al. Homocysteine and dementia: an international consensus statement. J Alzheimers Dis. 2018;62:561–70.CrossRefGoogle Scholar
  77. 77.
    Locher JL, Robinson CO, Roth DL, Ritchie CS, Burgio KL. The effect of the presence of others on caloric intake in homebound older adults. J Gerontol – Ser A Biol Sci Med Sci. 2005;60:1475–8.CrossRefGoogle Scholar
  78. 78.
    Kistler BM, et al. Eating during hemodialysis treatment: a consensus statement from the International Society of Renal Nutrition and Metabolism. J Ren Nutr. 2018;28:4–12.CrossRefGoogle Scholar
  79. 79.
    Veeneman JM, et al. Protein intake during hemodialysis maintains a positive whole body protein balance in chronic hemodialysis patients. Am J Physiol – Endocrinol Metab. 2003;284:E954–65.CrossRefGoogle Scholar
  80. 80.
    Fouque D, et al. Use of a renal-specific oral supplement by haemodialysis patients with low protein intake does not increase the need for phosphate binders and may prevent a decline in nutritional status and quality of life. Nephrol Dial Transplant. 2008;23:2902–10.CrossRefGoogle Scholar
  81. 81.
    Cano NJ, et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol. 2007;18:2583–91.CrossRefGoogle Scholar
  82. 82.
    Marsen TA, Beer J, Mann H. Intradialytic parenteral nutrition in maintenance hemodialysis patients suffering from protein-energy wasting. Results of a multicenter, open, prospective, randomized trial. Clin Nutr. 2017;36:107–17.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Vincenzo Bellizzi
    • 1
    • 2
  • Filippo Aucella
    • 3
  • Patrizia Calella
    • 4
  • Philippe Chauveau
    • 2
    • 5
  • Lina Johansson
    • 2
    • 6
  • Daniel Teta
    • 2
    • 7
  1. 1.Division of Nephrology, Dialysis and Transplantation, Nephrology UnitUniversity Hospital “San Giovanni di Dio e Ruggi d’Aragona”SalernoItaly
  2. 2.European Renal Nutrition (ERN) Working Group at the European Renal Association – European Dialysis Transplant Association (ERA-EDTA)LondonUK
  3. 3.Department of Nephrology and DialysisScientific Institute for Research and Health Care “Casa Sollievo della Sofferenza” IRCCSSan Giovanni RotondoItaly
  4. 4.Department of Movement Sciences and WellbeingParthenope UniversityNaplesItaly
  5. 5.Aurad Aquitaine et Service de NéphrologieCHU de BordeauxBordeauxFrance
  6. 6.Department of Nutrition and DieteticsImperial College Healthcare NHS TrustLondonUK
  7. 7.Service of NephrologyHospital of Sion and University of LausanneLausanneSwitzerland

Personalised recommendations