NUTRITION

Ways of nutritional support

Dietary counselling (Ikizler et al., 2020)

Patients should be encouraged to increase his/her nutritional intake by:

• Modifying and/or liberate diet according to individualized needs
• Providing small frequent meals and low potassium and phosphate energy dense snacks
• In case or early satiety, patients should be advised to consume protein foods first if they are on dialysis. As those not on dialysis tend to need less protein, it is important that dietary advice in this situation doesn’t encourage high levels of protein.
• Patients should be advised to choose energy dense/ low volume dietary choices.

Food Fortification

In case of more profound malnutrition food fortification can be used to increase energy and protein intake. Fortification is the addition of nutrients to common foods to increase energy and protein intake.(Ikizler et al., 2020)

Energy fortification can be established with the addition of fat and carbohydrates in the food. Common ways of achieving that is the addition of:

• olive oil, vegetable oils, margarine, butter
• sugar and honey in absence of diabetes mellitus
• specific products that provide energy by fat and carbohydrates.

Protein fortification can be achieved with the addition of:

• Egg whites and cream cheese
• commercially available protein powers or liquid protein supplements mainly from casein or collagen

ONS

If nutritional counseling alone fails to improve nutritional status, Oral nutritional supplements (ONS) can be used. (Fiaccadori et al., 2021)

Oral Nutritional supplements for CKD patients are usually:

• energy dense, providing >1.5 Kcal/ ml to avoid fluid overload
• Low in potassium, sodium and phosphate whilst containing micronutrients

They can cover the needs of patients who are able to cover 20 Kcal/kg/day per day and 0.8g/kg/day from spontaneous energy and protein intake respectively.

IDPN

In stable undernourished maintenance haemodialysis patients with low compliance or tolerance to ONS can have intradialytic parenteral nutrition (IDPN) considered (Chan, 2021)

Intradialytic parenteral nutrition is:

• a cyclic parenteral nutrition (PN) provided during haemodialysis through the venous way of the dialysis line, three times per week.
• It provides 15-20 Kcal/kg (800-1200 Kcal in total) and 0.5-1g/ kg protein (30-60 g/session) per HD session, in the form of fat, carbohydrate and protein
• It equals to the nutritional support of 400-600 Kcal /day. (Sabatino et al., 2014)
• If not supplemented with micronutrients, it doesn’t contain any vitamins or minerals therefore is not a whole source of nutrition

IDPN is administered via an infusion pump that can overcome venous pressure in the dialysis blood lines. This fluid is then mixed with the patient’s venous blood and returned to the body through the venous access. During IDPN, up to 1lt of parenteral nutrition can be administered at a maximum rate of 250 ml/h, to be able to infuse 1lt in 4 hours.(Carrero et al., 2023)