Adjusted Edema-Free BodyWeight (aBWef)

The body weight to be used for assessing or prescribing protein

or
energy intake is the aBWef. For hemodialysis patients, this should
be
obtained postdialysis. For peritoneal dialysis patients, this should
be
obtained after drainage of dialysate. (Opinion)
The adjusted edema-free body weight should be used for maintenance
dialysis patients who have an edema-free body weight less than 95% or
greater than 115% of the median standard weight, as determined from
the
NHANES II data.
For individuals whose edema-free body weight is between 95% and
115% of the median standard weight, the actual edema-free body weight
may be used.
For DXA measurements of total body fat and fat-free mass, the actual
edema-free body weight obtained at the time of the DXA measurement
should be used.
For anthropometric calculations, the postdialysis (for MHD) or postdrain
(for CPD) actual edema-free body weight should be used.
The wide range in body weight and body composition observed among
dialysis patients seriously limits the use of the actual body weight for
assessment or prescription of nutritional intake. The use of the actual or
unadjusted body weight to assess the actual nutrient intake or to
prescribe the intake of energy and protein can be hazardous when
individuals are very obese or very underweight. On the other hand, it may
be hazardous to ignore the effects of the patients body size on dietary
needs and tolerance in individuals who are markedly underweight or
overweight. It is recognized that the determination of the patients
edema-free body weight is often difficult and not precise. Clinical
judgement based on physical examination and, if necessary, body
composition measurements are used to estimate the presence or absence
of edema.
The following equation can be used to calculate the edema-free adjusted
body weight
(aBWef)63:
aBWef _ BWef _ [(SBW _ BWef) _ 0.25]
Equation 1
whereBWef is the actual edema-free body weight and SBW is the standard
body weight as determined
from the NHANES II data.89 Since interdialytic weight gain (IDWG) can be
as high as 6 to 7 kg in HD patients, and peritoneal dialysate plus
intraperitoneal ultrafiltrate can reach 2 to 5 kg, the aBWef should be
calculated based on postdialysis values for HD patients and post-dialysate
drain measurements for peritoneal dialysis patients. Equation 1 takes into
account the fact that themetabolic needs and dietary protein and energy

requirements of adipose tissue in obese individuals is less than that of

edema-free lean body mass
RAT I O NALE
The findings from many studies that MHD patients have a high incidence
of PEM underscores the importance of maintaining an adequate nutrient
intake.128,129 Although there are numerous causes for malnutrition,
decreased nutrient intake is probably the most important. Causes of poor
nutrient intake include anorexia from uremia itself, the dialysis procedure,
intercurrent illness, and acidemia. Inadequate intake is also caused by
comorbid physical illnesses affecting gastrointestinal function, depression,
psychiatric illness, organic brain disease, or socioeconomic factors.
Removal of amino acids (about 10 to 12 g per HD),130-132 some
peptides,133 low amounts of protein (_1 to 3 g
per dialysis, including blood loss), and small quantities of glucose (about
12 to 25 g per dialysis if glucose-free dialysate is used) may contribute to
PEM. Hypercatabolism from a chronic inflammatory state, associated
illnesses, dialysis procedure itself, or acidemia may also induce
malnutrition.134-137
DPI is often reported to be low in MHD patients. A number of publications
have described
the mean DPI of individuals treated with MHD to vary from about 0.94 to
1.0 g protein/kg/ d.57,138-140 Hence, approximately half of MHD patients
ingest less than this quantity of protein. Few studies have directly
assessed the dietary protein requirements for MHD patients. No
prospective long-term clinical trials have been conducted in which
patients are randomly allocatedto different dietary protein levels and the
effects of protein intake on morbidity, mortality, or quality of life have
been assessed. Several prospective nutritional-metabolic studies have
compar dietary protein intakes. The current guideline is recommended to
provide assurance that almost all clinically stable CPD patients will have
good protein nutrition. Patients who do not have an adequate DPI should
first receive dietary counseling and education. If DPI remains inadequate,
oral supplements should be prescribed. If the oral supplementsare not
tolerated or effective and protein malnutrition is present, consideration
should be given to use of tube feedings to increase protein intake. Amino
acids may be added to dialysate to increase amino acid intake and to
replace amino acid losses in dialysateed the effects of different levels of
DPI on nutritional status. Most of these latter studies have been carried
out in in-hospital clinical research centers, and hence, the numbers of
patients studied have been small.57,58,137,139 Taken together, these
studies suggest that a DPI of about 1.2 g/kg/d is necessary to ensure
neutral or positive nitrogen balance in most clinically stable MHD patients.

Daily Energy Intake for Maintenance Dialysis Patients

The recommended daily energy intake for maintenance hemodialysis
or chronic peritoneal dialysis patients is 35 kcal/kg body weight/d for
those who are less than 60 years of age and 30 to 35 kcal/kg body

weight/d for individuals 60 years or older. (Evidence and Opinion)

Energy expenditure of patients undergoing maintenance hemodialysis or

continuous ambulatory peritoneal dialysis is similar to that of normal,
healthy individuals.

Metabolic balance studies of people undergoing maintenance hemodialysis

indicate that a total daily energy intake of about 35 kcal/kg/d induces
neutral nitrogen balance and is adequate to maintain serum albumin and
anthropometric indices.

Because individuals more than 60 years of age tend to be more sedentary,

a total energy intake of 30 to 35 kcal/kg is acceptable

tthat MD patients frequently have low energy intake and are underweight, often despite receiving
apparently adequate dialysis therapy.128,153 Low body weights (adjusted for height, age, and gender) are
associated with increased mortality rates in MD patients.15,50,85,86 Hence, it would seem important to
aggressively attempt to maintain adequate energy intakes. Dietary energy requirements have been studied
in MHD patients under metabolic balance conditions. Dietary energy requirements were examined in six
MHD patients while they ingested diets providing 25, 35, and 45 kcal/kg/d and a DPI of 1.13 g/kg/d for 21
days each. These studies indicated that the mean energy intake necessary to maintain both neutral nitrogen
balance and unchanging body composition was about 35 kcal/kg/d. 58 The finding that energy expenditure
in MHD and CPD patients appears to be normal corroborates the observations from the aforementioned
nitrogen balance and body composition studies.154-157 Based on the aforementioned studies, it is
recommended that MHD patients consume a diet with a total daily energy intake of 35 kcal/kg body
weight/d. For CPD patients, the recommended total daily energy intake, including both diet and the energy
intake derived from the glucose absorbed from peritoneal dialysate, should be 35 kcal/kg/d. Most of the
patients who participated in these studies were younger than 50 years of age, and this recommendation is
therefore made only for individuals less than 60 years of age. Because older age may be associated with
reduced physical activity and leanbody mass, a daily energy intake of 30 to 35 kcal/kg/d for older patients
with more sedentary lifestyles is acceptable. These recommendations are approximately the same as those
for normal adults of the same age who are engaged in mild daily physical activity as indicated in the
Recommended Dietary Allowances (RDA

Intensive Nutritional CounselingWith Maintenance Dialysis (MD)

Every MD patient should receive intensive nutritional counseling
based on an individualized plan of care developed before or at the time
of commencement of MD therapy. (Opinion)

A plan of care for nutritional management should be developed before or

during the early phase of MD care and modified frequently based on the
patients medical and social conditions.

The plan of care should be updated at least every 3 to 4 months.

Nutrition counseling should be intensive initially and provided thereafter

every 1 or 2 months and more frequently if inadequate nutrient intake or
malnutrition is present or if adverse events or illnesses occur that may
cause deterioration in nutritional status

L-Carnitine for Maintenance Dialysis Patients

There are insufficient data to support the routine use of L-carnitine for
maintenance dialysis patients. (Evidence and Opinion)

Although the administration of L-carnitine may improve subjective

symptoms such as malaise, muscle weakness, intradialytic cramps and
hypotension, and quality of life in selected maintenance dialysis patients,
the totality of evidence is insufficient to recommend its routine provision
for any proposed clinical disorder without prior evaluation and attempts at
standard therapy

The most promising of proposed applications is treatment of erythropoietinresistant anemia

RAT I O NALE
The use of L-carnitine inMDpatients is attractive on the theoretical level, because it is well known that
patients undergoing MD usually have low serum free L-carnitine concentrations and that skeletal muscle
carnitine is sometimes decreased. Because L-carnitine is known to be an essential co-factor in fatty acid
and energy metabolism, and patients on dialysis tend to be malnourished, it might follow that repletion of
L-carnitine by the intravenous or oral route could improve nutritional status, particularly among patients
with low dietary L-carnitine intakes. L-carnitine has been proposed as a treatment for a variety of
metabolic abnormalities in ESRD, including hypertriglyceridemia, hypercholesterolemia, and anemia. It
has also been proposed as a treatment for several symptoms or complications of dialysis, including
intradialytic arrhythmias and hypotension, low cardiac output, interdialytic and post-dialytic symptoms of
malaise or asthenia, general weakness or fatigue, skeletal muscle cramps, and decreased exercise capacity
or low peak oxygen consumption. Studies using L-carnitine for each of these potential indications were
reviewed. Randomized clinical trials were given particular consideration, although the evidence was not
restricted to these studies, many of which are summarized in Appendix
X.
There was complete agreement that there is insufficient evidence to support the routine
use of L-carnitine for MD patients. In selected individuals who manifest the above symptoms or disorders
and who have not responded adequately to standard therapies, a trial of L-carnitine may be considered. In
reaching these conclusions, we considered the strength of available evidence as well as the alternative
therapies available for each potential indication