Malnutrition in Dialysis

  • Raj Kumar SharmaEmail author
  • Sonia Mehrotra
Living reference work entry


Malnutrition continues to be a problem in chronic kidney disease (CKD) patients on hemodialysis (HD), resulting in increased morbidity and mortality. Factors that reduce food intake and increase hypercatabolism play important role in malnutrition seen in dialysis patients. Various factors contributing to malnutrition syndrome in dialysis are anorexia due to uremia with electrolyte and hormone imbalances, metabolic abnormalities, gastrointestinal disorders, psychological factors, severe dietary restriction, social problems, increased inflammation, hypercatabolism, and nutrient losses during hemodialysis and peritoneal dialysis. Detecting malnutrition in CKD patients is very challenging. Dialysis patients commonly show protein depletion and energy deficit. The term protein-energy wasting (PEW) syndrome describes the loss of body protein mass and reduction in calorie reserves in dialysis patients. Some dialysis patients can also get overweight or obese and do not appear to have energy deficit but may have protein malnutrition. PEW syndrome is associated with a poor prognosis. The pathogenesis of PEW is incompletely understood and has multifactorial etiopathogenesis. Comorbidities and under-dialysis also contribute to anorexia and malnutrition in dialysis. Intra-dialysis hyperalimentation may be provided for patients who continue to lose weight despite oral supplementation (at least 50% or more of the prescribed caloric intake).


Chronic kidney disease Dialysis Malnutrition syndrome Protein-energy wasting Malnutrition management 

List of Abbreviations


Body mass index


Chronic kidney disease


End-stage renal disease


Glomerular filtration rate


Intradialytic Parenteral Nutrition


Maintenance hemodialysis


Protein-energy wasting


Protein nitrogen appearance


  1. Alp Ikizler T, Cano NJ, Franch H et al (2013) 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 84:1096–1107CrossRefPubMedGoogle Scholar
  2. Anderton N, Giri A, Wei G et al (2015) Sedentary behavior in individuals with diabetic chronic kidney disease and maintenance hemodialysis. J Ren Nutr 25:364CrossRefPubMedPubMedCentralGoogle Scholar
  3. Antunes AA, Delatim Vannini F, de Arruda Silveira LV, Martin LC, Barretti P, Caramori JC (2010) Influence of protein intake and muscle mass on survival in chronic dialysis patients. Ren Fail 32(9):1055–1059CrossRefPubMedGoogle Scholar
  4. Atkin-Thor E, Goddard BW, O’Nion J et al (1978) Hypogeusia and zinc depletion in chronic dialysis patients. Am J Clin Nutr 31:1948CrossRefPubMedGoogle Scholar
  5. Avery-Lynch M (2006) Intradialytic parenteral nutrition in hemodialysis patients: acute and chronic intervention. CANNT J 16(2):30–33PubMedGoogle Scholar
  6. Axelsson J, Heimbürger O, Lindholm B, Stenvinkel P (2005) Adipose tissue and its relation to inflammation: the role of adipokines. J Ren Nutr 15:131CrossRefPubMedGoogle Scholar
  7. Barton Pai A, Chretien C, Lau AH (2002) The effects of nandrolone decanoate on nutritional parameters in hemodialysis patients. Clin Nephrol 58:38CrossRefPubMedGoogle Scholar
  8. Beddhu S, Wei G, Marcus RL et al (2015) Light-intensity physical activities and mortality in the United States general population and CKD subpopulation. Clin J Am Soc Nephrol 10:1145CrossRefPubMedPubMedCentralGoogle Scholar
  9. Bossola M, Muscaritoli M, Tazza L et al (2005) Malnutrition in hemodialysis patients: what therapy? Am J Kidney Dis 46:371CrossRefPubMedGoogle Scholar
  10. Bossola M, Tazza L, Giungi S, Luciani G (2006) Anorexia in hemodialysis patients: an update. Kidney Int 70:417CrossRefPubMedGoogle Scholar
  11. Cano N, Luc G, Stroumza P, Lacombe P, Durbec JP (1994) Serum lipoprotein changes after prolonged intralipid infusion in malnourished haemodialysis patients. Clin Nutr 13(2):111–115CrossRefPubMedGoogle Scholar
  12. Cano NJ, Fouque D, Roth H, Aparicio M, Azar R, Canaud B et al (2007) Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol 18(9):2583–2591CrossRefPubMedGoogle Scholar
  13. Carrero JJ, Witasp A, Stenvinkel P et al (2010) Visfatin is increased in chronic kidney disease patients with poor appetite and correlates negatively with fasting serum amino acids and triglyceride levels. Nephrol Dial Transplant 25:901CrossRefPubMedGoogle Scholar
  14. Chen H-S, Cheng C-T, Hou C-C, Liou H-H, Chang C-T, Lin C-J et al (2017) A practical standardized composite nutrition score based on Lean Tissue Index: application in Nutrition Screening and Prediction of Outcome in Hemodialysis Population. J Ren Nutr 27(4):267–274CrossRefPubMedGoogle Scholar
  15. Cohen SD, Norris L, Acquaviva K et al (2007) Screening, diagnosis, and treatment of depression in patients with end-stage renal disease. Clin J Am Soc Nephrol 2:1332CrossRefPubMedGoogle Scholar
  16. de Brito-Ashurst I, Varagunam M, Raftery MJ, Yaqoob MM (2009) Bicarbonate supplementation slows progression of CKD and improves nutritional status. J Am Soc Nephrol 20:2075CrossRefPubMedPubMedCentralGoogle Scholar
  17. Druml W, Kierdorf HP (2009) Parenteral nutrition in patients with renal failure – guidelines on parenteral nutrition, Chapter 17. Ger Med Sci 7:Doc11PubMedPubMedCentralGoogle Scholar
  18. Duenhas MR, Draibe SA, Avesani CM et al (2003) Influence of renal function on spontaneous dietary intake and on nutritional status of chronic renal insufficiency patients. Eur J Clin Nutr 57:1473CrossRefPubMedGoogle Scholar
  19. Garibotto G, Barreca A, Russo R et al (1997) Effects of recombinant human growth hormone on muscle protein turnover in malnourished hemodialysis patients. J Clin Invest 99:97CrossRefPubMedPubMedCentralGoogle Scholar
  20. Garibotto G, Sofia A, Russo R, Paoletti E et al (2015) Insulin sensitivity of muscle protein metabolism is altered in patients with chronic kidney disease and metabolic acidosis. Kidney Int 88(6):1419–1426CrossRefPubMedPubMedCentralGoogle Scholar
  21. Gascón A, Belvis JJ, Berisa F et al (1999) Nandrolone decanoate is a good alternative for the treatment of anemia in elderly male patients on hemodialysis. Geriatr Nephrol Urol 9:67CrossRefPubMedGoogle Scholar
  22. Gordon PL, Sakkas GK, Doyle JW, Shubert T, Johansen KL (2007) Relationship between vitamin D and muscle size and strength in patients on hemodialysis. J Ren Nutr 17:397–407CrossRefPubMedPubMedCentralGoogle Scholar
  23. Iglesias P, Díez JJ, Fernández-Reyes MJ et al (1998) Recombinant human growth hormone therapy in malnourished dialysis patients: a randomized controlled study. Am J Kidney Dis 32:454CrossRefPubMedGoogle Scholar
  24. Ikizler TA (2005) Effects of hemodialysis on protein metabolism. J Ren Nutr 15:39CrossRefPubMedGoogle Scholar
  25. Ikizler TA, Flakoll PJ, Parker RA, Hakim RM (1994) Amino acid and albumin losses during hemodialysis. Kidney Int 46(3):830–837CrossRefPubMedGoogle Scholar
  26. Ikizler TA, Pupim LB, Brouillette JR et al (2002) Hemodialysis stimulates muscle and whole body protein loss and alters substrate oxidation. Am J Physiol Endocrinol Metab 282:E107CrossRefPubMedGoogle Scholar
  27. Johansen KL, Mulligan K, Schambelan M (1999) Anabolic effects of nandrolone decanoate in patients receiving dialysis: a randomized controlled trial. JAMA 281:1275CrossRefPubMedGoogle Scholar
  28. K/DOQI, National Kidney Foundation (2000) Clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 35:S1Google Scholar
  29. Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD (2003) Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis 42(5):864–881CrossRefPubMedGoogle Scholar
  30. Kalantar-Zadeh K, Block G, McAllister CJ et al (2004) Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients. Am J Clin Nutr 80:299CrossRefPubMedGoogle Scholar
  31. Kalantar-Zadeh K et al (2013) Patient education for phosphorus management in chronic kidney disease. Patient Prefer Adher 7:379–390CrossRefGoogle Scholar
  32. Kalantar-Zadeh K, Brown A, Chen JLT, Kamgar M, Lau W-L, Moradi H, Rhee CM, Streja E, Kovesdy CP (2015) Dietary restrictions in Dialysis patients: is there anything left to eat? Semin Dial 28(2):159–168CrossRefPubMedPubMedCentralGoogle Scholar
  33. Kaysen GA, Greene T, Daugirdas JT et al (2003) Longitudinal and cross-sectional effects of C-reactive protein, equilibrated normalized protein catabolic rate, and serum bicarbonate on creatinine and albumin levels in dialysis patients. Am J Kidney Dis 42:1200CrossRefPubMedGoogle Scholar
  34. Kaysen GA, Greene T, Larive B et al (2012) The effect of frequent hemodialysis on nutrition and body composition: frequent hemodialysis network trial. Kidney Int 82:90CrossRefPubMedPubMedCentralGoogle Scholar
  35. Kirushnan BB, Subba Rao B, Annigeri R, Balasubramanian S et al (2017) Impact of malnutrition, inflammation, and atherosclerosis on the outcome in hemodialysis patients. Indian J Nephrol 27(4):277–283CrossRefPubMedPubMedCentralGoogle Scholar
  36. Kopple JD (1999) Therapeutic approaches to malnutrition in chronic dialysis patients: the different modalities of nutritional support. Am J Kidney Dis 33:180CrossRefPubMedGoogle Scholar
  37. Kopple JD, Cheung AK, Christiansen JS et al (2011) OPPORTUNITY & trade: a large-scale randomized clinical trial of growth hormone in hemodialysis patients. Nephrol Dial Transplant 26:4095CrossRefPubMedGoogle Scholar
  38. Kramer HJ, Saranathan A, Luke A et al (2006) Increasing body mass index and obesity in the incident ESRD population. J Am Soc Nephrol 17:1453CrossRefPubMedGoogle Scholar
  39. Marzocco S, Dal Piaz F, Di Micco L et al (2013) Very low protein diet reduces indoxyl sulfate levels in chronic kidney disease. Blood Purif 35:196CrossRefPubMedGoogle Scholar
  40. Mehrotra S, Rishishwar P, Sharma RK (2015) Malnutrition and hyperphosphatemia in dialysis patients. Clin Queries 4:25–27CrossRefGoogle Scholar
  41. Mehrotra S, Sharma RK, Patel MR et al (2016) Fibroblast growth factor-23, vitamin D and mineral metabolism in renal transplant recipients. Indian J Transplant 10(1):1–4CrossRefGoogle Scholar
  42. Mekki K, Remaoun M, Belleville J, Bouchenak M (2012) Hemodialysis duration impairs food intake and nutritional parameters in chronic kidney disease patients. Int Urol Nephrol 44(1):237–244CrossRefPubMedGoogle Scholar
  43. Mitch WE, Remuzzi G (2004) Diets for patients with chronic kidney disease, still worth prescribing. J Am Soc Nephrol 15:234CrossRefPubMedGoogle Scholar
  44. Neyra R, Chen KY, Sun M et al (2003) Increased resting energy expenditure in patients with end-stage renal disease. JPEN J Parenter Enteral Nutr 27:36CrossRefPubMedGoogle Scholar
  45. Pupim LB, Flakoll PJ, Brouillette JR et al (2002) Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. J Clin Invest 110:483CrossRefPubMedPubMedCentralGoogle Scholar
  46. Ramkumar N, Cheung AK, Pappas LM et al (2004) Association of obesity with inflammation in chronic kidney disease: a cross-sectional study. J Ren Nutr 14:201CrossRefPubMedGoogle Scholar
  47. Sharma R, Agrawal S, Saxena A, Sharma RK (2013a) Association of IL-6, IL-10 and TNF-α gene polymorphism with malnutrition inflammation syndrome and survival in end stage renal disease. J Interf Cytokine Res 33(7):384–391CrossRefGoogle Scholar
  48. Sharma R, Agrawal S, Saxena A, Pandey M, Sharma RK (2013b) Association of genetic variants of ghrelin, leptin and UCP2 with malnutrition inflammation syndrome and survival in end-stage renal disease. Genes Nutr 8(6):611. Accepted for publication in Genes and NutritionCrossRefPubMedPubMedCentralGoogle Scholar
  49. Shinaberger CS, Kilpatrick RD, Regidor DL, McAllister CJ, Greenland S, Kopple JD, Kalantar-Zadeh K (2006) Longitudinal associations between dietary protein intake and survival in hemodialysis patients. Am J Kidney Dis 48(1):37–49CrossRefPubMedGoogle Scholar
  50. Siew ED, Pupim LB, Majchrzak KM et al (2007) Insulin resistance is associated with skeletal muscle protein breakdown in non-diabetic chronic hemodialysis patients. Kidney Int 71:146CrossRefPubMedGoogle Scholar
  51. Stolic R, Trajkovic G, Stolic D, Peric V, Subaric-Gorgieva G (2010) Nutrition parameters as hemodialysis adequacy markers. Hippokratia 14(3):193–197PubMedPubMedCentralGoogle Scholar
  52. Streja E, Lau WL, Goldstein L et al (2013) Hyperphosphatemia is a combined function of high serum PTH and high dietary protein intake in dialysis patients. Kidney Int Suppl 3:462CrossRefGoogle Scholar
  53. Terrier N, Jaussent I, Dupuy AM, Morena M, Delcourt C, Chalabi L, Rouanet C et al (2008) Creatinine index and transthyretin as additive predictors of mortality in haemodialysis patients. Nephrol Dial Transplant 23(1):345–353CrossRefPubMedGoogle Scholar
  54. Tripathi G, Sharma R, Sharma RK, Gupta SK et al (2010) Vitamin D receptor genetic variants among patients with end-stage renal disease. Ren Fail 32(8):969–977CrossRefPubMedGoogle Scholar
  55. Wang XH, Mitch WE (2014) Mechanisms of muscle wasting in chronic kidney disease. Nat Rev Nephrol 10(9):504–516CrossRefPubMedPubMedCentralGoogle Scholar
  56. Wang AY-M, Sanderson J, Sea MM-M, Wang M, Lam CW-K et al (2003) Important factors other than dialysis adequacy associated with inadequate dietary protein and energy intakes in patients receiving maintenance peritoneal dialysis. Am J Clin Nutr 27(4):834–841CrossRefGoogle Scholar
  57. Wang X, Hu Z, Hu J et al (2006) Insulin resistance accelerates muscle protein degradation: activation of the ubiquitin-proteasome pathway by defects in muscle cell signaling. Endocrinology 147:4160CrossRefPubMedGoogle Scholar
  58. Zha Y, Qian Q (2017) Protein Nutrition and Malnutrition in CKD and ESRD. Nutrients 9:208, 3–19CrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NephrologySanjay Gandhi Post Graduate Institute of Medical SciencesLucknowIndia

Personalised recommendations