Nephrol Dial Transplant (2002) 17: 563-572
© 2002 European Renal Association-European Dialysis and Transplant Association
Special Feature
Nutritional status in dialysis patients: a European consensus
1 Department of Nephrology and Dialysis, Azienda Ospedale di Lecco, Ospedale A. Manzoni, Lecco, Italy, 2 Department of Nephrology, Hôpital Edouard Herriot, Lyon, France, 3 Division of Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden, 4 Department of Nephrology and Inserm U507, Necker Hospital, Paris, France, 5 Bone and Mineral Research Unit, Instituto Reina Sofia de Investigación, Hospital Central de Asturias, Universidad de Oviedo, Oviedo, Spain, 6 Division of Nephrology and Dialysis, Department of Medicine III, University of Vienna, Vienna, Austria, and 7 Department of Nephrology, University of Heidelberg, Heidelberg, Germany
Abstract
Background. Malnutrition is common in dialysis patients and closely related to morbidity and mortality. Therefore, assessment of nutritional status and nutritional management of dialysis patients play a central role in everyday nephrological practice.
Methods. Achieving a consensus on key points relating to pathogenesis, clinical assessment, and nutritional management of dialysis patients.
Results. The assessment of nutritional status should be based on clinical assessment and biochemical parameters, including history of weight loss, per cent standard weight, body mass index, muscle mass, subcutaneous fat mass, and plasma albumin, creatinine, bicarbonate and cholesterol. Co-morbid conditions should be assessed and C-reactive protein (CRP) measured—as a marker of inflammation—as there is a close relation between malnutrition, on one side, and co-morbid conditions and inflammation on the other. For a more detailed assessment, subjective global assessment of nutritional status is a well-validated tool, and dual-energy X-ray absorptiometry (DEXA) is a useful method for routine assessment of lean body mass. Anthropometric methods are also useful. They are cheap and easy to apply, although less precise than DEXA. The recommended daily protein intake is at least 1.2 g/kg standard body weight and the energy intake 35 kcal/kg standard body weight (BW), in patients <60 years, and 30 kcal/kg standard BW in patients >60 years. The standard bicarbonate level should be at least 22 mmol/l. If CRP is >10 mg/l, it is important to seek and treat the underlying cause. Adequate dialysis (for haemodialysis: Kt/V >1.2) should be ensured and, although no definite evidence of the importance of dialysis water quality is available, the opinion of the authors is that the water quality should be high. The role of the biocompatibility of the dialysis membrane is still not clear. The dietitian plays a pivotal role in the nutritional care of dialysis patients, and patients should be provided with dietary counselling from the start of substitutive treatment in order to meet the recommended nutritional intakes. Dietary counselling can also play an important role in an integrated treatment of hyperphosphataemia, although most patients will also need phosphate binders if they have an adequate protein intake.
Conclusion. Malnutrition assessment and treatment is a great challenge for nephrological care. Achieving evidence-based consensus can help in implementing the progress of knowledge in clinical practice.
Keywords: acidosis; catabolism; dietary counselling; dietary supplements; dietician; inflammation; lean body mass; malnutrition; nutritional status
Notes
Correspondence and offprint requests to: Prof. Dr Francesco Locatelli, Department of Nephrology and Dialysis, Ospedale A. Manzoni, Via Dell'Eremo 11, I-23900 Lecco, Italy. Email: nefrologia{at}ospedale.lecco.it
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