Nutrition in Patients On Peritoneal Dialysis PDF

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Nutrition in patients on peritoneal dialysis

Seung-Hyeok Han and Dae-Suk Han
Abstract | Proteinenergy wasting (PEW) is prevalent among patients on dialysis and has emerged as an
important risk factor for morbidity and mortality in these patients. Numerous factors, including inflammation,
inadequate dialysis, insufficient nutrient intake, loss of protein during dialysis, chronic acidosis, hypercatabolic
illness and comorbid conditions, are involved in the development of PEW. The causes and clinical features
of PEW in patients on peritoneal dialysis and hemodialysis are comparable; assessment of the factors that
lead to PEW in patients receiving peritoneal dialysis is important to ensure that PEW is managed correctly in
these patients. For the past 20years, much progress has been made in the prevention and treatment of PEW.
However, the results of most nutritional intervention studies are inconclusive. In addition, the multifactorial
and complicated pathogenesis of PEW makes it difficult to assess and treat. This Review summarizes the
nutritional issues regarding the causes, assessment and treatment of PEW, with a focus on patients receiving
peritoneal dialysis. In addition, an in-depth overview of the results of nutritional intervention studies is provided.
Han, S.H. & Han, D.S. Nat. Rev. Nephrol. 8, 163175 (2012); published online 7 February 2012; doi:10.1038/nrneph.2012.12
Introduction
Dialysis is now established as a successful therapy for
the management of patients with end-stage renal disease
(ESRD). To further improve patient outcomes, much
emphasis has focused on optimizing the adequacy of
dialysis, managing blood pressure and anemia and
maintaining biochemical parameters within the target
range. When compared with these issues, however, the
importance of proteinenergy wasting (PEW) seems to
be underestimated. Although much progress has been
made in improving the nutritional status of patients, the
prevalence of PEW in patients on dialysis remains high,
ranging from 18% to 56%, depending on the assessment
methods used.15 Accumulating evidence indicates that
PEW is an important predictor of morbidity and mortality in patients on dialysis and impairs quality of life. 69
Constant monitoring of nutritional status and early
detection, as well as therapeutic strategies for the prevention and treatment of PEW, are therefore crucial in the
management of patients on dialysis. A number of tools
are widely used in clinical practice for the assessment
of PEW, yet no single method comprehensively reflects
nutritional status, which should be cautiously assessed in
combination with other clinical and biochemical para
meters. Of note, however, no data have convincingly
demonstrated that improving PEW has a marked effect
on morbidity or mortality of patients.
The causes and features of PEW in patients on dialysis
are similar between those on hemodialysis and peritoneal dialysis10 and include inflammation, inadequate
protein and calorie intake, loss of appetite, loss of residual renal function (RRF), loss of protein during dialysis,
psychosocial factors, physical inactivity and comorbid
Competing interests
The authors declare no competing interests.
conditions.1114 Another important factor to note is that

peritoneal dialysis itself could suppress appetite.13,15
With these factors in mind, pertinent issues such as the
causes, pathogenesis, assessment and treatment of PEW
in patients on peritoneal dialysis are reviewed here.
Nomenclature
Malnutrition literally means bad nutrition and is usually
considered to entail undernutrition, which is characterized by low food intake and a modest decrease in serum
albumin levels; undernutrition can be corrected by
increasing nutrient intake. In patients with ESRD, this
form of malnutrition is sometimes termed type1 malnutrition.16 Another type of malnutrition also exists in
which an inflammation-associated wasting process is
involved. However, differentiating between these two
types of malnutrition is difficult and the majority of
patients on dialysis have both. To date, multiple terms
have been used (often interchangeably and confusingly)
to describe malnutrition in patients with ESRD, including uremic malnutrition, uremic cachexia, protein
energy malnutrition, malnutritioni nflammation
atheros clerosis (MIA) syndrome and malnutrition
inflammation complex. Moreover, multiple conditions
in patients with chronic kidney disease (CKD), such
as inflammation, nutrient loss during dialysis, chronic
acidosis, hypercatabolic illness, and endocrine dis
orders including resistance to insulin, growth hormone,
and insulin-like growth factor (IGF)I can cause loss of
muscle mass despite adequate nutrient intake.5,13 As the
altered nutritional status associated with these conditions is not solely attributed to reduced nutrient intake,
it cannot be corrected merely by increasing intake.
To avoid confusion, the term PEW was proposed by a
panel of experts from the International Society of Renal
NATURE REVIEWS | NEPHROLOGY
Division of Nephrology,
Department of Internal
Medicine, Yonsei
University College of
Medicine, 50 Yonsei-ro
Seodaemun-gu, Seoul
120-752, Korea
(S.H.Han, D.S. Han).
Correspondence to:
D.S. Han
dshan@yuhs.ac
VOLUME 8 | MARCH 2012 | 163

2012 Macmillan Publishers Limited. All rights reserved
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Key points
Proteinenergy wasting (PEW) is common and is an important risk factor for
morbidity and mortality in patients on dialysis
Inflammation, inadequate dialysis, insufficient nutrient intake, loss of protein
during dialysis, chronic acidosis, hypercatabolic illness, comorbid conditions,
psychosocial factors and physical inactivity are involved in the development of
PEW
Peritoneal dialysis itself might lead to PEW as continuous glucose absorption
from peritoneal dialysis solutions, abdominal fullness induced by the dialysate
and peritonitis can suppress appetite
No single test is precisely indicative of PEW; comprehensive diagnostic
criteria for PEW proposed by the International Society of Renal Nutrition and
Metabolism could be useful
A number of treatment options for PEW are available but improving nutritional
status is difficult and no data have convincingly shown that nutritional
intervention improves patient survival
A multidisciplinary approach to PEW management should be provided by
providing nutritional assessment and support, dietary counseling, management
of comorbid conditions, and by maintaining an adequate dialysis dose and
preserving residual renal function
Nutrition and Metabolism (ISRNM), 4 and is steadily

gaining acceptance. According to the ISRNM, PEW is
the state of decreased body stores of protein and energy
fuels (that is, body protein and fat masses). PEW is
characterized by markedly decreased serum albumin
levels, the presence of inflammation and oxidative stress
and greater levels of protein breakdown than synthesis.
A reduced muscle mass seems to be the most valid criterion for the presence of PEW. In addition, the ISRNM
panel recommends that cachexia is differentiated from
PEW and used to denote a severe form of PEW, often
associated with profound physiological, metabolic,
psychological and immunological disorders.4 Based on
the suggestion by the ISRNM panel, in this Review we
use the term PEW instead of malnutrition to avoid problems in interpretation when nutritional problems occur
in patients with CKD.
Causes and pathogenesis of PEW

Inflammation
In patients with ESRD, inflammation is common
and leads to atherosclerosis and arteriosclerosis,
which eventually results in increased cardiovascular
morbidity and mortality. Moreover, elevated levels of
Creactive protein (a serum inflammatory marker)
predicts mortality independently of other comorbidities in patients on peritoneal dialysis.17 Inflammation,
alone or in combination with other factors, also has a
key role in the pathogenesis of PEW. Indeed, malnutrition (that is, PEW), inflammation and atherosclerosis
coordinate together in a vicious cycle of so called MIA
syndrome16 and have been associated with high rates
of morbidity and mortality. In particular, the 2year
mortality rate increased up to 70% in patients who had
all three components of MIA syndrome compared with
approximately 10% or less in patients who had none of
these components.18,19
Several mechanisms have been proposed to explain
how inflammation is involved in PEW. First, pro
inflammatory cytokines could cause muscle wasting by
164 | MARCH 2012 | VOLUME 8
increasing protein hydrolysis and muscle-protein breakdown through activation of the ubiquitinproteasome
proteolytic pathway or nuclear factor B signaling.20
In addition, inflammation can suppress appetite and
induce anorexia. In fact, elevated plasma levels of tumor
necrosis factor were found in patients with anorexia
on peritoneal dialysis compared with levels in patients
without anorexia.21 Inflammation-associated anorexia
was reported to be mediated by leptina hormone
that suppresses appetite. Indeed, blocking leptin signaling through the hypothalamic melanocortin 4 receptor improved uremic cachexia in a mouse model. 22
Furthermore, visfatin, a newly identified adipocytederived factor that is sensitive to inflammation, might
also contribute to uremic anorexia.23
A second mechanism involves insulin resistance.
Insulin is an anabolic hormone that exerts anticatabolic
effects on skeletal muscle.24 Inflammatory cytokines
disturb insulin signaling pathways, which results in
decreased insulin sensitivity.25 This effect, in turn, might
dampen the anabolic effect of insulin on skeletal muscle
and cause loss of muscle mass. Indeed, insulin resistance
correlated with muscle wasting in 21 patients on peritoneal dialysis,26 which suggests that insulin resistance is
closely linked with PEW.
Other peritoneal dialysis-related factors that might
cause inflammation include poor oral health, volume
overload, peritonitis, and bioincompatible solutions;2729
of note, these factors (unlike those discussed above) are
potentially reversible. In fact, when the uid status of 25
patients on peritoneal dialysis was well-controlled, nutritional status and inflammation were improved, whereas
fluid overload resulted in worse nutritional status and
promoted inflammation.28
Inadequate nutritional intake

The Kidney Dialysis Outcomes Quality Initiative
(KDOQI) guidelines recommend a daily energy
intake of 35kcal/kg for patients on peritoneal dialysis
<60years and 3035kcal/kg for patients >60years and
daily protein intake of 1.21.3g/kg.30 However, a large
proportion of patients on peritoneal dialysis ingest a
considerably lower amount of calories and protein than
the recommended amounts.31,32 Moreover, inadequate
dietary protein intake (DPI) is associated with increased
all-cause and cardiovascular mortality in these patients.9
Despite inadequate protein or energy intake, one study
showed that glucose absorption from the dialysate can
provide some energy 33 and another study demonstrated
that the nitrogen balance in the majority of patients on
peritoneal dialysis is positive.34
Nutrient intake by patients on dialysis can be influenced by many factors: inflammation, taste abnormalities, gastrointestinal problems, medications, physical
inactivity, dietary restrictions, emotional and psychological disorders and social constraints such as poverty
(Figure1).3537 Factors that are specific to peritoneal
dialysis might also be associated with poor oral intake as
continuous absorption of glucose from peritoneal dialysis solutions15,38 and abdominal fullness induced by the
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dialysate13 can cause loss of appetite. Interestingly, gastric
emptying was delayed in patients receiving peritoneal
dialysis.39 However, whether this delay is attributed to
dialysate dwell perse or to the absorption of substrate
substances with caloric and metabolic activity such as
glucose is uncertain.40
Ghrelin, a gut peptide that regulates hunger by stimulating neuropeptide Y and agouti-related peptide in
the hypothalamus, has been identified as an appetite
enhancer.41 Paradoxically, circulating ghrelin levels were
increased in patients on dialysis when compared with
levels in healthy controls,42 which suggests that these
patients are resistant to ghrelin. Nevertheless, plasma
ghrelin levels were markedly lower in anorexic patients
on peritoneal dialysis than in those with normal appetite.43 Interestingly, as exchange with peritoneal dialysis
solution lowers ghrelin levels,44 a reduced level of ghrelin
might mediate this anorexic effect.
Bioincompatibility of peritoneal dialysis solution might also influence appetite: in a rat model, a
bicarbonatelactate solution suppressed appetite to
a lesser extent than a lactate solution. 45 No clinical
evidence, however, exists to support this finding.
Loss of nutrients into dialysate

Although waste products are cleared during dialysis treatment, nutrients are also lost into the dialysate.
Patients on peritoneal dialysis lose approximately 912g
of total protein and 68g of albumin daily.5,46 Loss of
protein is much greater during an episode of peritonitis.46 In particular, the type of peritoneal membrane
transport might influence the amount of protein loss.
In patients with a fast peritoneal solute transport rate
(that is, high transporters), protein losses are considerably greater than in patients with a low solute transport
rate.47 Relevant to this finding is our observation that
a fast peritoneal solute transport rate is independently
associated with poor nutritional status in patients on
peritoneal dialysis.48 Fast peritoneal solute transport
rates have also been associated with inflammation49 and
mortality in some studies;50,51 however, other studies have
found no association between peritoneal transport rate
and nutritional status.52,53 Of note, high risk of adverse
outcomes in high transporters was only observed in
those on continuous ambulatory peritoneal dialysis; no
relationship between peritoneal transport rate and either
mortality or transfer to hemodialysis has been reported
for patients receiving automated peritoneal dialysis.54,55
In addition, inherent fast transport (that is, when the
patient has a fast solute transport rate from the start of
peritoneal dialysis) and acquired fast transport (that is,
when the transport rate increases with time on peritoneal
dialysis) might have different clinical implications; inherent fast transport is associated with increased mortality
because it is linked with greater levels of comorbidity
and inflammation than acquired fast transport.56 Such
discrepancy between findings regarding the relationship
between peritoneal transport types and nutritional
status can be explained by differences in study design,
number of enrolled patients, patient characteristics, the
Factors related to uremia
Factors related to peritoneal dialysis
Inflammation
Loss of nutrients
into dialysate
Inadequate dialysis
Loss of residual
renal function
Anorexia
Inadequate
nutrient intake
Appetite loss due to

glucose absorption
from dialysate
Proteinenergy
wasting
Abdominal discomfort
induced by dialysate
Hypercatabolism
Chronic acidosis
Comorbid conditions:
diabetes mellitus,
cardiovascular disease,
infection
Peritonitis
Bioincompatible
solution?
Figure 1 | The causes of proteinenergy wasting in patients on peritoneal dialysis.
timing of evaluation of peritoneal transport type and

nutritional assessments. Further investigations using
more detailed methods such as the diagnostic criteria
proposed by the ISRNM panel are required to delineate
the association between peritoneal transport types and
nutritional status.
Loss of residual renal function

Over the past 20years, the importance of preserving RRF
has been highlighted in many aspects of the management
of patients on dialysis and low RRF is an independent
risk factor for adverse outcomes in these patients. 12,57
From a nutritional viewpoint, numerous reports have
indicated that RRF is also important in determining
nutritional status. In one study, preserved RRF was
independently associated with a greater intake of dietary
protein, calories and other nutrients, whereas peritoneal
dialysis solute clearance was not.11 In addition, resting
energy expenditure was found to be inversely correlated
with RRF, which suggests that patients with decreased
RRF have an altered protein metabolism.58 Furthermore,
a number of studies have shown that patients with preserved RRF have a better nutritional status, as determined using different assessment methods such as
lean body mass (LBM), normalized protein catabolic
rate (nPCR), subjective global assessment (SGA) score,
DPI, serum albumin level, and handgrip strength than
patients who have low or no RRF.11,5961 Moreover, loss
of RRF is associated with increased systemic inflammation.62 Given the importance of inflammation as a
key mediator of muscle wasting and anorexia, loss of
RRF can be presumed to contribute to PEW through
exacerbated inflammation.
A decrease in middle molecule clearance is also
clearly evident as RRF declines63 and this effect might
adversely affect nutritional status. Whether increasing
the removal of middle molecules improves nutritional
status, however, remains to be further explored as their
increased removal by high-flux dialysis failed to improve
nPCR in patients on hemodialysis.64

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Box 1 | ISRNM criteria for diagnosis of PEW in patients with ESRD
A diagnosis of PEW requires that at least three out of the four listed categories
should be met and at least one test in each of the selected category should be
included.
Serum chemistry
Serum albumin level (measured using the bromocresol green method) <38g/l
Serum prealbumin level (transthyretin) <30mg/dl
Serum cholesterol level <2.59mmol/l (not valid if low concentrations are
caused by abnormally high urinary or gastrointestinal protein losses, liver
disease or cholesterol-lowering medicines)
Body mass
BMI <22kg/m2 65years, <23kg/m2 >65years (a lower BMI might be
desirable for certain Asian populations; weight must be edema-free mass)
Unintentional weight loss over time: 5% over 3months or 10% over 6months
Total body fat percentage <10%
Muscle mass
Muscle wasting: reduced muscle mass 5% over 3months or 10% over
6months
Reduced MAMC area as measured by a trained anthropometrist (reduction
>10% in relation to the 50th percentile of the reference population)
Creatinine appearance (of note, appearance is influenced by muscle mass and
meat intake)
Dietary intake
Unintentionally low DPI <0.80g/kg per day for at least 2months (which
can be assessed by dietary diaries and interviews, or for protein intake by
calculation of the normalized protein equivalent of total nitrogen appearance
[normalized protein nitrogen appearance or normalized protein catabolic rate]
as determined by urea kinetic measurements
Unintentional low DEI <25kcal/kg per day for at least 2months
Abbreviations: DEI, dietary energy intake; DPI, dietary protein intake; ESRD, end-stage renal
disease; ISRNM, International Society of Renal Nutrition and Metabolism; MAMC, mid-arm
muscle circumference; PEW, proteinenergy wasting.
Hypercatabolic state
Patients with PEW on dialysis are characterized by a
hypercatabolic state that is promoted by numerous
factors including inflammation, negative protein and
energy balance during dialysis, diabetic complications,
concurrent infection or sepsis, comorbid conditions such
as cardiovascular disease, acidosis and resistance to IGFI
and growth hormone.37
Possible mechanisms of acidosis-induced PEW are
protein degradation, protein breakdown from skeletal muscle and oxidation of branched-chain amino
acids,65 a decrease in albumin synthesis,66 and reduced
expression of IGFI and growth hormone. 67 Many
cross-sectional studies have shown a direct relationship
between the severity of metabolic acidosis and nutritional status in patients with CKD.68 We observed that
patients on peritoneal dialysis with serum bicarbonate
levels of 1820mmol/l (associated with mild to moderate acidosis) had a favorable nutritional status.69,70
However, detailed analysis revealed that patients with
severe metabolic acidosis (that is, serum bicarbonate
levels <18mmol/l) had low serum albumin levels and
high composite nutritional index scores. These findings
suggest that acidosis has a protein catabolic effect, which
leads to poor nutrition in severely acidotic patients.70
Why mild to moderate metabolic acidosis was associated with favorable nutritional status is unclear, but high
protein intake in well-dialyzed patients can partly explain
this finding. Of note, however, this cross-sectional study
does not prove causality. The therapeutic target of bicarbonate levels 22mmol/l as suggested by the KDOQI
guideline seems to be reasonable, given the considerable
concern about protein degradation and muscle wasting
in patients with persistent acidosis.30
PEW resulting from resistance to growth hormone and
IGFI occurs in patients who have an abnormal growth
hormoneIGF axis despite normal or high levels of
endogenous growth hormone and IGFI.71 Furthermore,
high levels of IGF-binding proteins in these patients
reduces the amount of free IGFI.71 As growth hormone
exerts an anabolic effect and thereby induces protein
preservation and denovo protein synthesis,72 the abnormal growth hormoneIGF axis in uremia shifts the metabolic balance from anabolism to catabolism. By contrast,
increased serum levels of catabolic hormones (such as
glucagon and parathyroid hormone) and deficiency in
1,25-dihydroxycholecalciferol might also promote the
development of PEW.5
Assessment of nutritional status

A wide variety of clinical and biochemical methods are
available to detect PEW in patients with ESRD. BMI,
SGA score, anthropometric measurements, biochemical parameters (such as serum albumin level) and DPI
have traditionally been used in clinical practice; however,
no single method is precisely indicative of PEW. Many
investigators therefore cautiously interpret data combined
from several parameters rather than from a single test.
The ISRNM panel have proposed comprehensive diagnostic criteria for PEW in patients with CKD (Box1).4
The criteria consist of four main categories (serum chemistry, body mass, muscle mass and dietary intake) that
encompass both clinical and biochemical features of PEW.
A clinical diagnosis of PEW according to the ISRNM
guidelines requires that at least three out of the four listed
categories (and at least one test in each of the selected
categories) are satisfied. The panel also recommended
helpful additional measures of nutrition and inflammation, which include assessment of appetite, food intake
and energy expenditure; body mass and composition;
laboratory markers; and nutritional scoring systems.
Although each test in the four main categories can
be readily used to test for PEW in patients on dialysis, several considerations should be made when these
criteria are applied to those on peritoneal dialysis.
Serum chemistry
Among various biochemical parameters, low serum
albumin concentration is a strong predictor of mortal
ity in patients on peritoneal dialysis. 73 Indeed, our
25years experience with peritoneal dialysis has shown
that decreased serum albumin levels are independently
associated with mortality.74 However, as serum albumin
has a long half-life of approximately 20days and can
be affected by inflammation, losses into dialysate and
fluid status, levels of serum albumin should be interpreted with caution when diagnosing PEW. 13,28,75 By
contrast, prealbumin has a relatively short half-life (of
approximately 2days), and so is considered to be a more
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sensitive marker of nutritional status than albumin.
However, prealbumin can also be lost into dialysates and
its levels in serum are higher in patients on peritoneal
dialysis than in those on hemodialysispossibly owing
to the increased hepatic synthesis in response to its
peritoneal loss.76
Body mass
Epidemiological studies indicate the presence of an
obesity paradox (that is, a high BMI is associated with
survival) in patients on maintenance dialysis.77 Indeed,
in patients on hemodialysis and peritoneal dialysis, a
low BMI is associated with an increased risk of mortality.78,79 However, BMI can be affected by fat mass or
hydration status. In particular, peritoneal dialysis often
leads to greater volume expansion than hemodialysis,80
which suggests that BMI might not be a useful parameter
of nutritional status in patients on peritoneal dialysis.
Interestingly, the survival advantage associated with a
higher BMI is less apparent in patients on peritoneal
dialysis than in those on hemodialysis.79,81 Furthermore,
the majority of studies that show this obesity paradox in
patients on dialysis were conducted in the USA. In fact,
obesity was associated with worse outcomes in a study
of patients on peritoneal dialysis in Australia and New
Zealand;82 an analysis that pools patients on hemodialysis
and peritoneal dialysis might not, therefore, be appropriate. Defining BMI as indicative of PEW in patients
on peritoneal dialysis might need to be individualized
depending on the patient population.
Muscle mass
Muscle wasting is a key feature of PEW. In fact, a reduced
muscle mass with high BMI (so-called sarcopenic
obesity) was associated with inflammation and increased
mortality in patients with ESRD, although the patients
with these characteristics were indeed obese as assessed
by BMI.83,84 Anthropometric assessment of mid-arm
muscle circumference is commonly used to measure
muscle mass. However, this method can be insensitive as
it is associated with a substantial interobserver error and
is affected by hydration status.13 As for BMI, interpretation of parameters of muscle mass in patients on peritoneal dialysis should be made after a careful consideration
of fluid status.
Dietary intake
Dietary intake as assessed by dietary diaries and interviews, even when a dietitian is involved, can be subjective and inaccurate. The accuracy of determining dietary
intake depends on the reliability of patients to properly
quantify the amount of food eaten.85 In fact, in a study of
40 patients on peritoneal dialysis, a significant number of
patients (particularly those who were overweight) were
found to under-report energy intake as evaluated by
3day food diaries.86 In addition, estimation of DPI using
a urea kinetic model can be unreliable in patients who
are in anabolic or catabolic states and can be confounded
by the concomitant loss of protein into, or energy intake
from, the dialysate.85
The ISRNM panel recommended other potential tools

for assessment of PEW that include scoring systems
such as the SGA score and malnutritioninflammation
scoreboth of which are widely used in clinical practice.
However, the accuracy of these scoring systems depends
on the examiner and considerable training is required
to ensure consistent and steady results. In addition, no
consensus has been reached on the relationship of these
subjective assessments in the diagnosis of PEW.4
Prevention and treatment of PEW

As PEW is multifactorial in origin, a single therapeutic
strategy is unlikely to be successful. Although a number
of treatment options are available, restoring normal
nutritional status in patients with PEW on dialysis is
difficult and no data exist that convincingly show that
nutritional intervention improves patient survival. Here,
we provide an overview of the management of PEW in
patients on peritoneal dialysis.
Dialysis dose
Accumulation of uremic toxin with CKD progression is
associated with anorexia.87 In clinical practice, patients
with anorexia commonly regain appetite after dialysis is
initiated; however, whether increasing dialysis dose leads
to better clinical outcomes is still debated. Observational
studies have suggested a link between dialysis adequacy
and nutritional status;8,11,88 however, although several
prospective longitudinal studies have investigated
whether increasing dialysis dose improves nutritional
status in patients on peritoneal dialysis,8993 the results
of these have been inconclusive and limited by short
follow-up duration and small sample size. In one of these
studies, an increase in dialysis-derived calories and creatinine appearance, as well as stabilization of weight and
mid-arm circumference, was observed in malnourished
patients after dialysis dose was increased.93 Objective
measures of improvement, such as increased serum
albumin level, were marked in patients without comorbid
disease. By contrast, other studies found no improvement
in either serum albumin level or normalized protein
nitrogen appearance (nPNA) despite an increase in
Kt/V.89,92 Moreover, secondary analyses of the Adequacy
of Peritoneal Dialysis in Mexico (ADEMEX) trial94 and
of an interventional study conducted in six centers in
Hong Kong 95 found no association between higher dialysis dose and improved nutritional status. To date, only
one prospective, randomized study has investigated the
link between dialysis dose and nutritional status; increasing Kt/V from 1.82 to 2.02 over 12months resulted
in an increase in nPNA from 1.10g/kg to 1.24g/kg,
whereas no improvement was observed in serum
albumin level, SGA score, LBM or DPI.96 Interestingly,
reports have suggested that the relationship between
Kt/V and nPNA is not linear but reaches a plateau at a
weekly Kt/V of approximately 1.8.9799 This finding is in
line with the secondary analyses of the ADEMEX trial
and Hong Kong study. Depending on the baseline dialysis dose, therefore, increasing the dialysis dose could
improve nutritional status in some patients. However,

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the effects of increments beyond a certain point seem
to be attenuated.
If underdialysis is suspected in patients with anorexia
and declining nutritional status on peritoneal dialysis,
the dialysis dose should be increased to optimize dialysis adequacy. Alternatively, combined peritoneal dialysis
and hemodialysis therapy might be helpful in improving nutritional status. Indeed, nPNA, creatinine generation rate and LBM significantly increased after adding a
once weekly hemodialysis session to 56days per week
of peritoneal dialysis regimen in patients affected by
underdialysis or fluid overload.100
Preservation of RRF
As loss of RRF is associated with deterioration in nutritional status, preservation of RRF could be assumed
to maintain nutritional status. Prospective, randomized intervention studies are not feasible, however, as
RRF declines over time. Moreover, RRF is influenced
by many factors and cannot be easily manipulated.
One study showed a marked decline in the nutritional
status of patients on peritoneal dialysis who lost RRF.93
Furthermore, RRF had a considerable effect on nutritional status as nutritional intake was affected to a greater
extent by RRF than by peritoneal dialysis solute clearance,11 which supports the findings from a previous
study.101 Given the large contribution of RRF to nutritional status and patient outcome, various efforts to preserve RRF in patients on dialysis should be an essential
part of PEW prevention strategies.
Dietary counseling
In patients on peritoneal dialysis, regular and comprehensive assessments to identify factors that cause PEW
are mandatory. Of note, only 39% of 266 patients on peritoneal dialysis complied with a DPI of 1.2g/kg per day as
recommended by the KDOQI guidelines.102 Therefore,
dietary counseling might be useful if inadequate nutritional intake is a problem. Indeed, a marked improvement in nutrient intake and in grades of malnutrition
was observed in 283 patients on peritoneal dialysis after
repeated dietary counseling.103 However, the results of
two prospective studies were inconsistent with each
other.104,105 In particular, a randomized, controlled trial
that included 54 patients on peritoneal dialysis demonstrated that a substantial proportion of these patients
were unable to increase protein and energy intake over
4 months, even though dietary advice was provided.105
Although DPI 1.21.3g/kg per day is generally recommended for patients on peritoneal dialysis, the optimal
target has not yet been determined. In fact, the European
guidelines suggest a protein intake 1.0g/kg per day 106
and a study of Chinese patients on peritoneal dialysis
showed that DPI >0.94g/kg per day was associated with
favorable nutritional status and long-term outcomes.9
Interestingly, both this study and the European guidelines warned against lower DPIs of <0.8 and 0.73g/kg per
day, respectively.9,106 Furthermore, an intake of 1.0g/kg
per day seems to be sufficient in nitrogen balance studies
of patients on peritoneal dialysis.34,107 These findings
therefore support the rationale for reducing the target

DPI to a minimum of 1.0g/kg per day.106,108
Oral supplements
Various oral nutritional supplements that provide energy
or protein sources or a combination of both are available for patients on dialysis. Table1 presents a summary
of studies that have examined the effects of oral supplements on the nutritional status of patients on peritoneal
dialysis. 109117 A nonrandomized study showed that
serum albumin levels and protein catabolic rate (PCR)
increased significantly after adding 0.10.3g/kg per day
of high biological value protein to the diet of elderly
patients on peritoneal dialysis.109 Subsequently, randomized controlled trials showed that an increase in protein
intake using polymeric diets112 or an egg albumin supplement 115 considerably increased serum albumin levels,
whereas other types of supplement, such as amino acid
tablets or protein drinks, did not.111,114 Nutritional supplements also led to a significant improvement in serum
albumin levels in patients on dialysis, but only in those
on hemodialysis.116 Moreover, in a randomized crossover
study in patients on hemodialysis and peritoneal dialysis,
nPCR was stably maintained and serum albumin levels
were slightly increased in patients who received a protein
supplement, whereas both parameters were decreased in
patients who did not receive the protein supplement.117
Despite inconsistent results, oral nutritional supplements
are encouraged in clinical practice for patients with PEW
on peritoneal dialysis.
Oral appetite stimulants
Megestrol acetate is recommended for the treatment of
patients with anorexia and cancer or AIDS. This appetite stimulant is an orally active, synthetic derivative of
naturally occurring progesterone that increases appetite
by stimulating neuropeptide Y in the hypothalamus and
exerts anti-inflammatory effects by downregulating
proinflammatory cytokines.118 Clinical experience with
megestrol acetate in patients on dialysis is limited. To our
knowledge, only three studies have examined the effects
of megestrol acetate in patients on peritoneal dialysis.
One of these studies showed that low-dose megestrol
(40mg per day) administered for 4months increased
appetite and serum albumin levels in 12 patients on
peritoneal dialysis and in four on hemodialysis.119 Two
subsequent studies using 160mg
per day
of megestrol for 123months obtained similar findings. 120,121
Unfortunately, as all of these studies were uncontrolled,
the reported positive results need, in our opinion, further
confirmation through well-designed, controlled studies.
Furthermore, the long-term use of megestrol has raised
safety concerns as adverse effects, including thrombo
embolic phenomena, uterine bleeding, peripheral edema,
hyperglycemia, hypertension and adrenal insufficiency,
have been widely reported.122
Amino acid solutions
A unique feature of peritoneal dialysis is the large loss
of 34g per day of amino acids and 912g per day of
REVIEWS
Table 1 | Effects of oral supplements on nutritional status in patients on peritoneal dialysis
Study
Study type
Population
Interventions
Follow-up
Results
Shimomura
etal. (1993)109
Nonrandomized
controlled
36
Supplement of 0.10.3g protein per kg

per day (n=18); controls had no
supplement (n=18)
6months
serum albumin, prealbumin,

transferrin, plasma total amino acids,
and the ratio of essential amino
acids to nonessential amino acids
Heaf etal.
(1999)110
No control group
14
Commercial supplement with 40g

protein per day
10weeks
No change in serum albumin, DPI,

calorie intake and nPNA
Eustace etal.
(2000)111
Randomized double
blind placebo-controlled
47 (18 on PD
and 29 on HD)
Oral essential amino acid tablets vs

placebo
3months
No change in serum albumin level or

grip strength; skinfold thickness
Aguirre Galindo
etal. (2003)112
Randomized
100
High protein diet (1.4g/kg per day)

(n=50) vs calcium caseinate diet
(n=50)
4months
serum albumin level and total

protein in both groups
Boudville etal.
(2003)113
Single blind crossover
13 on PD
Commercial supplement with 475kcal

and 16.6g protein
ND
serum albumin level, total calorie

and protein intake
Teixid-Planas
etal. (2005)114
Randomized controlled
75
Commercial supplement with 20g of

protein per day
12months
No change in serum albumin level;

high rate of noncompliance and
intolerance to commercial protein
supplement
GonzlezEspinoza etal.
(2005)115
Randomized controlled
30
Egg albumin supplement with 30g

protein per day (n=13); control (n=15)
6months
serum albumin, total calorie and

protein intake, and nPNA
Poole and
Hamad
(2008)116
No control group
190 (157 on
HD and 33 on
PD)
2030g protein and 500kcal per day for

nondiabetics; 13.8g protein and
250kcal per day for diabetics
3months
serum albumin (HD only); no

significant improvement in PD
Moretti etal.
(2009)117
Randomized crossover
49 (6 on PD
and 43 on HD)
PD: 105g protein per week; HD: 45g

protein per week
12months
No change nPCR and serum

albumin level in protein
supplemented group; nPCR and
serum albumin level in controls
Abbreviations: DPI, dietary protein intake; HD, hemodialysis; ND, not determined; nPNA, normalized protein nitrogen appearance; nPCR, normalized protein catabolic rate; PD, peritoneal dialysis.
proteins into the dialysate.5,46 One exchange with a 1.1%

amino acid solution can compensate for these losses and
meet the nutritional requirements in patients on peritoneal dialysis. A 6h dwell time with a 1.1% amino acid
solution enables approximately 16g (7278%) of amino
acids to be absorbed, which is greater than the peritoneal loss of amino acids using conventional glucose
solutions.123 Anabolic effects are also induced as muscle
protein synthesis and IGFI levels are increased, which
reduces muscle protein breakdown.124 The results from
some studies support the use of an amino acid-based
dialysis solution in patients with PEW, as they have
demonstrated improvement in several biochemical and
anthropometric nutritional parameters and a positive
nitrogen balance (Table2).125134 However, these findings are not consistent with those from other studies
(Table3).135139 Our long-term observations, however,
support the use of amino acid-based dialysis solutions, as
daily use of an amino-acid based solution for 12 months
resulted in significant increases in nutritional para
meters, including LBM, hand grip strength and nPNA
in patients with PEW on peritoneal dialysis.134
Metabolic acidosis is a potential adverse effect of
amino acid-based dialysis solutions. 127 However, in
agreement with previous studies,140 we observed that
although bicarbonate levels decreased, levels of bicarbonate remained within the normal range. 134 To date,
only two randomized clinical trials examined the effects
of amino acid-based solutions on clinical outcomes or
nutritional status in patients on peritoneal dialysis.130,133
Of these two studies, only one examined the mortality

rate and showed that patient survival and incidence
of peritonitis did not differ between patients receiving amino acid-based solutions and those receiving glucose-based solutions over a 3year follow-up,
although some nutritional parameters such as nPNA
and DPI improved in the former group. The second
study only examined changes in nutritional status.133
Interpretation of published data on the effects of
amino acid-based solutions should therefore be made
with caution because most studies that have demonstrated positive effects of amino acid-based solutions
on outcomes have been small and observational, and
it is therefore uncertain whether an amino acid-based
solution confers a clinical benefit.
Hormonal treatments
As patients on dialysis are frequently hypercatabolic,
stimulation of muscle protein anabolism is therefore an
attractive therapeutic option to avoid muscle wasting.
Anabolic hormones that have been tested include
growth hormone, IGFI and androgenic anabolic steroids (Table4). As mentioned earlier, altered growth
hormoneIGFI axis and growth hormone resistance are
potential mechanisms for PEW in patients on dialysis;
nearly all of the studies that have evaluated the nutritional effects of recombinant human growth hormone
(rhGH) have demonstrated the anabolic effects of
decreases in blood urea nitrogen levels and nPNA.141
These effects have been consistently observed in patients

REVIEWS
Table 2 | Studies showing positive effects of 1.1% amino acid-based solution in patients on peritoneal dialysis
Study
Study type
Population
Interventions
Follow-up
Result
Bruno etal.
(1989)125
Crossover
One exchange of a 1.1% amino

acid-based solution
6months
nitrogen balance and MAMC; serum

bicarbonate
Arfeen etal.
(1990)126
Case series
Two exchanges of a 1.1% amino

acid-based solution
2months
serum albumin; serum bicarbonate
Kopple etal.
(1995)127
Case series
19
12 exchanges of a 1.1% amino

acid-based solution
20days
nitrogen balance, BUN and transferrin;

serum bicarbonate
Faller etal.
(1995)128
Case series
15

acid-based solution
3months
serum albumin, BUN and transferrin;

no change in serum bicarbonate
Chertow etal.
(1995)129
Observational
183

acid-based solution
Mean 6.6months
serum albumin; no change in serum

bicarbonate
Misra etal.
(1996)130
Randomized
crossover
18

acid-based solution
6months
Improved nutrition score; no change in serum

albumin and transferrin; serum albumin in
patients with baseline albumin <30.0g/l
Jones et al.
(1998)131
Randomized
controlled
134
One or two exchanges of a 1.1%

amino acid-based solution (n=71);
control (n=63)
3 months
IGF-I, serum albumin, prealbumin, and

transferrin; serum bicarbonate
Taylor etal.
(2002)132
Observational
22

acid-based solution
Mean 13.6months
serum albumin and nPCR; one episode

of peritonitis per 23 treatment months;
4% annual mortality rate
Li etal.
(2003)133
Randomized
controlled
60

acid-based solution (n=30);
control (n=30)
36months
nPNA and DPI; no change in mortality rate

and incidence of peritonitis
Park etal.
(2006)134
Observational
43

acid-based solution
12months
LBM, hand grip strength, nPNA and IGFI;

no change in serum albumin, prealbumin and
DPI; serum bicarbonate
Abbreviations: BUN, blood urea nitrogen; DPI, dietary protein intake; IGFI, insulin-like growth factor I; LBM, lean body mass; MAMC, mid-arm muscle circumference; nPNA, normalized protein
nitrogen appearance; nPCR, normalized protein catabolic rate.
Table 3 | Studies showing neutral effects of 1.1% amino acid-based solution in patients on peritoneal dialysis
Study
Study type
Population
Interventions
Follow-up
(months)
Results
Young etal.
(1989)135
Case series
One exchange of 1.1% amino

acid-based solution
No change in serum albumin or

prealbumin; no change in serum
bicarbonate; transferrin
Dombros etal.
(1990)136
Case series

acid-based solution
No change in serum albumin,

transferrin, DPI, DEI and skinfold
thickness; no change in serum
bicarbonate
Dibble etal.
(1990)137
Case series

acid-based solution
No change in total energy intake,

MAMC and skinfold thickness
Maurer et al.
(1996)138
Randomized
controlled
18
One or two exchanges of a

1.1% amino acid-based
solution (n=9); control (n=9)
No change in serum albumin,

transferrin, and LBM; no change
in serum bicarbonate
Grzegorzewska
etal. (1999)139
Case series
16

acid-based solution with
antacid (n=8); control (n=8)
No change in serum albumin, LBM,

skinfold thickness, DPI and DEI;
no change in serum bicarbonate
Abbreviations: DEI, dietary energy intake; DPI, dietary protein intake; LBM, lean body mass; MAMC, mid-arm muscle circumference.
on peritoneal dialysis.142145 Our work has also shown

that rhGH treatment improves nitrogen balance and
increases LBM in malnourished patients on peritoneal
dialysis.143 Another possible anabolic treatment is IGFI,
which differs from growth hormone in that it is antilipolytic and reduces serum glucose levels. However, clinical
trials using recombinant IGFI (rIGFI) are scarce. Only
one pilot study in six patients with PEW on peritoneal
dialysis has shown that rIGFI treatment resulted in a
positive nitrogen balance.146
Similar to growth hormone and IGF1, androgenic

anabolic steroids also induce net muscle protein synthesis and inhibit protein catabolic processes.141 Although
most studies on androgen treatment for PEW have been
conducted in patients on hemodialysis, positive effects
on nutritional parameters have been reported in those
on peritoneal dialysis.147149 In a double-blind, randomized controlled trial, treatment of patients on peritoneal dialysis with oxymetholone for 6months resulted
in a significant increase in serum albumin levels and
REVIEWS
Table 4 | Effects of hormonal treatments on nutritional status in patients on peritoneal dialysis
Study
Study type
Population
Interventions
Follow-up
Results
Ikizler etal.
(1994)142
Crossover
10
rhGH 5mg per day
7days
BUN and total UNA; no change in DPI, transferrin

and prealbumin
Kang etal.
(1994)143
Case series
10
rhGH 10IU/m2 weekly
12weeks
nitrogen balance and maximum oxygen

consumption capacity; BUN and total UNA
Ikizler etal.
(1996)144
Crossover
10
rhGH 5mg per day
7days
Iglesias etal.
(1998)145
Randomized
controlled
rhGH group (n=8);

control (n=9)
rhGH 0.2IU/kg per day
4weeks
body weight, IGFI, and transferrin; BUN;

no change in DPI and serum albumin
Case series
rhIGFI 100g/kg per

12h
35days
nitrogen balance; BUN and urine nitrogen;

no change in serum albumin, MAMC and skinfold
thickness
Dombros
etal.
(1994)147
Observational
13
Nandrolone decanoate
100200mg monthly
3months
Johansen
etal.
(1999)148
Randomized doubleblind placebocontrolled
29 (9 PD and 20 HD);
androgen group (n=14);
placebo (n=15)
100mg weekly
6months
LBM, serum creatinine, and functional

improvement
Navarro etal.
(2002)149
Randomized
controlled
Androgen group (n=13);

EPO group (n=14)
200mg weekly
6months
serum albumin, prealbumin, transferrin, body

weight, MAMC and skinfold thickness; BUN and
total UNA
Aramwit etal.
(2010)150
Randomized doubleblind placebocontrolled
Oxymetholone (n=11);
placebo (n=13)
Oxymetholone 50mg
twice daily
6months
Wynne etal.
(2005)152
Randomized doubleblind crossover
A single injection of
ghrelin (3.6nmol/kg)
Ashby etal.
(2009)153
Randomized doubleblind crossover
12 (3 on PD and 9 on
HD)
Ghrelin (3.6nmol/kg)
daily
7days
Growth hormone
Essential amino acids in plasma and dialysate
IGF-I
Fouque etal.
(2000)146
Androgen
serum albumin; no change in BUN
serum albumin and LBM
Ghrelin
Energy intake; appetite, but no difference
between ghrelin and saline group
Energy intake; appetite
Abbreviations: BUN, blood urea nitrogen; DPI, dietary protein intake; EPO, erythropoietin; HD, hemodialysis; LBM, lean body mass; MAMC, mid-arm muscle circumference; PD, peritoneal
dialysis; rHGH; recombinant human growth hormone; rhIGFI, recombinant human insulin-like growth factor I; UNA, urea nitrogen appearance.
LBM.150 However, the long-term efficacy and risk of

adverse effects have not yet been determined in patients
with ESRD.
The role of ghrelin as an appetite enhancer is currently
being investigated.151 To date, only two studiesboth of
randomized, double-blind, crossover design and performed by the same grouphave explored the effects
of ghrelin in patients on dialysis. A single subcutaneous injection of ghrelin resulted in a substantial increase
in energy intake when compared with a placebo in nine
patients with PEW on peritoneal dialysis.152 These findings were subsequently confirmed using daily ghrelin
administration for an extended period of 7days in 12
patients on dialysis.153 Ghrelin therefore seems to directly
target appetite regulation, and is a potential treatment for
patients with PEW on peritoneal dialysis.
Correction of acidosis
A small study of seven patients on peritoneal dialysis
showed a decrease in protein degradation with correction of acidosis.154 In a randomized, single-blind study,
correction of metabolic acidosis led to increases in body
weight and mid-arm circumference in the first year of
continuous ambulatory peritoneal dialysis. 155 Using

a similar protocol, another study also showed that
the benef icial effects of acidosis correction on nutritional status were mediated by the downregulation of
branched-chain amino acid degradation and muscle
proteolysis via the ubiquitinproteasome system. 156
In addition, another randomized controlled trial
showed that treatment with oral sodium bicarbonate
for 12months resulted in increases in SGA score and
nPNA in patients on peritoneal dialysis with acidosis
and Kt/V <2.1.157 Furthermore, patients treated with
pure bicarbonate-buffered peritoneal dialysis solution
exhibited an improved nPCR compared with those
treated with lactate-buffered solution. Presumably, the
bicarbonate-buffered solution was better able to correct
acidosis than the lactate solution.158 Interestingly, even
within normal pH range, a greater positive nitrogen
balance was achieved in patients with a high-normal
(7.44) arterial pH than in those with a low-normal (7.37)
arterial pH.159 In line with these studies, the KDOQI
guidelines recommend a therapeutic target of bicarbonate levels of 22mmol/l in patients with ESRD who are
maintained on dialysis.30

REVIEWS
Box 2 | Management of PEW in peritoneal dialysis
General management
Maintain adequate dialysis dose
Correct acidosis
Manage comorbid or catabolic conditions
Dietary counseling
Encourage adequate food intake:
Daily energy intake 35kcal/kg of body weight for patients
<60years and 3035kcal/kg body weight for patients
>60years
Protein intake 1.21.3g/kg body weight per day*
Oral nutritional supplements
Peritoneal dialysis-related therapies
Preserve residual renal function
Prevent and treat peritonitis
Maintain optimal fluid balance
Utilize amino acid-based solutions
Use biocompatible solutions
Potential therapies
Appetite stimulants
Hormonal treatments (growth hormone; insulin-like
growth factor I; anabolic steroids; ghrelin)
Anti-inflammatory treatment
*1.0g/kg body weight per day can be acceptable unless there is
evidence of declining nutritional status. Abbreviation: PEW,
proteinenergy wasting.
Conclusions
Improving the poor nutritional status of patients with
PEW on peritoneal dialysis is difficult owing to the
multif actorial and complicated pathogenesis of this
disease. Early identification is key to rehabilitating these
malnourished patients and avoiding poor outcomes.
Thus, a multidisciplinary approach should be provided
through careful nutritional assessment, dietary counseling and proper nutritional support (Box2). In addition,
management of psychological illnesses and comorbid
conditions should not be ignored. Accurate monitoring
and evaluation of inflammation is of paramount importance given the fact that inflammation is a key mediator
of PEW. However, a paucity of data are available concerning the effect of anti-inflammatory therapies on
nutritional status.
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to peritoneal dialysis should also be considered. In
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morbidity and mortality but also nutritional status.
Prevention of peritonitis is also important as recurrent peritonitis impairs appetite and nutritional status.
Adequate nutritional support should be provided that
considers the inadequate calorie and protein intake in
patients on peritoneal dialysis as well as the substantial protein loss into the dialysate. In this regard, it is
tempting to use amino acid-based dialysis solutions to
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survival. Unfortunately, most nutritional intervention
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Author contributions
All authors contributed equally to all aspects of the
article.


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REVIEWS

Nutrition in patients on peritoneal dialysis

conditions.1114 Another important factor to note is that

NATURE REVIEWS | NEPHROLOGY

VOLUME 8 | MARCH 2012 | 163

Nutrition and Metabolism (ISRNM), 4 and is steadily

Causes and pathogenesis of PEW

Inadequate nutritional intake

2012 Macmillan Publishers Limited. All rights reserved

Loss of nutrients into dialysate

Factors related to uremia

Factors related to peritoneal dialysis

Appetite loss due to

Figure 1 | The causes of proteinenergy wasting in patients on peritoneal dialysis.

timing of evaluation of peritoneal transport type and

Loss of residual renal function

NATURE REVIEWS | NEPHROLOGY

VOLUME 8 | MARCH 2012 | 165

Assessment of nutritional status

2012 Macmillan Publishers Limited. All rights reserved

The ISRNM panel recommended other potential tools

Prevention and treatment of PEW

NATURE REVIEWS | NEPHROLOGY

VOLUME 8 | MARCH 2012 | 167

therefore support the rationale for reducing the target

2012 Macmillan Publishers Limited. All rights reserved

Supplement of 0.10.3g protein per kg

serum albumin, prealbumin,

Commercial supplement with 40g

No change in serum albumin, DPI,

Oral essential amino acid tablets vs

No change in serum albumin level or

High protein diet (1.4g/kg per day)

serum albumin level and total

Single blind crossover

Commercial supplement with 475kcal

serum albumin level, total calorie

Commercial supplement with 20g of

No change in serum albumin level;

Egg albumin supplement with 30g

serum albumin, total calorie and

2030g protein and 500kcal per day for

serum albumin (HD only); no

PD: 105g protein per week; HD: 45g

No change nPCR and serum

proteins into the dialysate.5,46 One exchange with a 1.1%

Of these two studies, only one examined the mortality

NATURE REVIEWS | NEPHROLOGY

VOLUME 8 | MARCH 2012 | 169

One exchange of a 1.1% amino

nitrogen balance and MAMC; serum

Two exchanges of a 1.1% amino

serum albumin; serum bicarbonate

12 exchanges of a 1.1% amino

nitrogen balance, BUN and transferrin;

One exchange of a 1.1% amino

serum albumin, BUN and transferrin;

One exchange of a 1.1% amino

serum albumin; no change in serum

One exchange of a 1.1% amino

Improved nutrition score; no change in serum

One or two exchanges of a 1.1%