Protein and Energy Requirements for Dialysis Patients Flashcards

A hemodialysis patient has been receiving ONS (oral nutritional supplements) for 3 months with no improvement in serum prealbumin (remains 12 mg/dL). What is the MOST appropriate next nutritional intervention?

Answer: Reassess for underlying causes (inflammation, inadequate dialysis, depression/anorexia), consider escalating to intradialytic parenteral nutrition (IDPN) or enteral tube feeding, and involve a multidisciplinary team

Failure to respond to ONS warrants systematic reassessment: rule out active inflammation (CRP elevation), inadequate dialysis dose, depression/anorexia, medication side effects, and malabsorption. Escalation to IDPN or enteral nutrition, with multidisciplinary involvement, is the appropriate next step.

Renal-specific oral nutritional supplements (ONS) differ from standard formulas in what key nutritional characteristic?

Answer: They are calorically dense (1.8–2.0 kcal/mL), fluid-restricted, and have lower levels of potassium, phosphorus, and sometimes protein compared to standard formulas

Renal-specific formulas (Nepro, Novasource Renal) are calorie-dense (1.8–2.0 kcal/mL) to maximize energy in small volumes (fluid restriction), and are formulated with lower potassium, phosphorus, and sodium compared to standard high-protein supplements.

The 'anabolic resistance' phenomenon in dialysis patients means that dietary protein has reduced effectiveness in stimulating muscle protein synthesis. What strategy BEST counteracts anabolic resistance?

Answer: Combining resistance exercise with evenly distributed adequate protein intake (≥25–30 g protein per meal), emphasizing leucine-rich sources

Anabolic resistance in dialysis patients is overcome by combining resistance exercise (most effective anabolic stimulus) with leucine-rich protein sources distributed across meals. Leucine activates mTOR-mediated muscle protein synthesis. ≥25–30 g protein per meal is the threshold for maximal stimulation in resistant muscle.

According to the protein balance concept, a stable HD patient with nPCR (normalized protein catabolic rate) of 0.8 g/kg/day is BEST described as:

Answer: Having inadequate dietary protein intake, at risk for negative nitrogen balance and protein-energy wasting

In stable HD patients, nPCR approximates dietary protein intake. nPCR of 0.8 g/kg/day falls below the KDOQI recommendation of ≥ 1.2 g/kg/day, indicating inadequate protein intake and risk for negative nitrogen balance and PEW.

A 28-year-old female dialysis patient is pregnant. How do protein and energy requirements change during pregnancy in the dialysis setting?

Answer: Protein increases to 1.5–1.8 g/kg/day and energy to 35–40 kcal/kg/day; intensive daily dialysis (≥36 hours/week) is recommended to reduce uremic toxin exposure to the fetus

Pregnancy on dialysis requires significantly increased protein (1.5–1.8 g/kg/day, adding ~20 g/day for fetal growth), higher energy intake (35–40 kcal/kg/day), intensive daily dialysis (36+ hours/week to reduce BUN < 50 mg/dL to minimize fetal uremia), and careful monitoring of all micronutrients.

Which of the following BEST describes the nutritional role of L-carnitine in hemodialysis patients?

Answer: L-carnitine is removed by HD and may be depleted; supplementation (IV post-HD or oral) may improve HD-related fatigue, muscle weakness, cramps, and anemia non-responsive to ESA therapy

L-carnitine is essential for mitochondrial fatty acid oxidation. HD removes carnitine each session, and renal synthesis is impaired in CKD. IV L-carnitine (20 mg/kg post-HD) may improve carnitine-deficiency symptoms including fatigue, dialysis-related hypotension, muscle cramps, and EPO-resistant anemia.