What nutritional markers and nutrients should be measured and supplemented in a malnourished dialysis patient with a nonhealing surgical wound and infected orthopedic hardware, and what treatments can optimize outcomes?

Nutritional Management for Malnourished Dialysis Patient with Infected Orthopedic Hardware and Nonhealing Surgical Wound

Comprehensive nutritional assessment and aggressive supplementation with high protein (1.5-2 g/kg/day) and energy (35 kcal/kg/day) intake, plus specific micronutrient supplementation including zinc, selenium, vitamin C, and water-soluble vitamins is essential for optimizing outcomes in this complex patient. 1, 2

Nutritional Assessment Markers

Essential Laboratory Tests

• Serum albumin and prealbumin (strongest predictive value for survival in dialysis patients) 1
• BMI calculation and assessment of weight loss over 6 months 1
• Selenium levels (critical for wound healing and immune function) 2
• Zinc levels (essential for wound healing, deficient in up to 44% of dialysis patients) 2
• Copper levels (deficiency can be fatal in dialysis patients) 2
• Vitamin C levels (essential for collagen synthesis) 2
• Folate and thiamine levels (commonly deficient in dialysis patients) 2
• Vitamin B6 levels (important for protein metabolism) 2

Nutritional Requirements and Supplementation

Macronutrients

• Protein intake: 1.5-2 g/kg/day (higher range due to combined surgical wound, infection, and dialysis) 1

  • At least 50% should be high biological value protein 1
  • This higher protein intake is supported by evidence showing improved nutritional indices in malnourished dialysis patients 3

• Energy intake: 35 kcal/kg/day (30-35 kcal/kg/day if patient is over 60 years) 1

  • Include energy from dialysate glucose absorption in calculations 1
  • Higher energy intake correlates with weight gain in malnourished dialysis patients 3

Micronutrients

• Water-soluble vitamins: Due to dialysis-induced losses 1, 2

  • Folic acid: 1 mg/day 1
  • Pyridoxine (B6): 10-20 mg/day 1
  • Vitamin C: 30-60 mg/day (up to 100 mg/day may be needed) 1, 2
  • Thiamine: Monitor and supplement based on levels 2

• Minerals and trace elements: 1, 2

  • Zinc: 15 mg/day (critical for wound healing) 1
  • Selenium: 50-70 μg/day 1
  • Copper: Consider IV administration of approximately 3 mg/day 2
  • Vitamin D: Adjust according to serum calcium, phosphorus, and PTH levels 1

• Mineral restrictions: 1

  • Phosphate: 800-1000 mg/day
  • Potassium: 2000-2500 mg/day
  • Sodium: 1.8-2.5 g/day
  • Fluid: 1000 ml + urine volume

Nutritional Support Strategy

Route of Administration

1. Oral nutrition with supplements (first choice): 1

   • High-protein, high-energy oral nutritional supplements (ONS) 1, 4
   • Target twice daily supplementation to add 10-12 kcal/kg and 0.3-0.5 g protein/kg daily 4

2. If oral intake is insufficient (covers <70% of requirements): 1, 4

   • Tube feeding with dialysis-specific formulas 1
   • Check formula content for phosphorus and potassium 1

3. If enteral nutrition is not feasible: 1

   • Consider intradialytic parenteral nutrition (IDPN) 1
   • For patients with infected orthopedic hardware, parenteral nutrition may be used interchangeably with enteral nutrition without increased infection risk 1

Additional Treatments to Optimize Outcomes

Wound Management

• Combine nutritional support with physical rehabilitation to maximize recovery of muscle strength and function 4
• Consider arginine supplementation, which has been shown to reduce infectious complications and hospital length of stay 1
• Ensure adequate dialysis prescription to minimize uremic toxins that can impair wound healing 1

Infection Management

• Aggressive treatment of the infected orthopedic hardware is essential, as infection increases catabolism 1
• Correct metabolic acidosis, which can contribute to protein catabolism 1
• Consider L-carnitine supplementation for erythropoietin-resistant anemia, though evidence is insufficient for routine use 1

Monitoring Response

• Regular assessment of weight, muscle mass, and functional capacity 4
• Monitor serum albumin and prealbumin levels to assess nutritional improvement 1
• Reassess micronutrient levels, especially for patients on continuous renal replacement therapy for more than two weeks 2

Common Pitfalls and Caveats

• Inadequate protein/energy provision: Failure of nutritional support may be due to inadequate meeting of dietary needs 3
• Standard reference ranges: Relying on standard reference ranges for the general population may be inappropriate for dialysis patients 2
• Relying solely on BMI: This may underestimate malnutrition, especially in overhydrated patients 4
• Neglecting physical rehabilitation: This will limit recovery of muscle strength and function 4
• Overlooking micronutrient losses: Dialysis effluent can contain significant amounts of essential vitamins and minerals 2
• Delayed intervention: Malnourished patients with surgical site infections have a 6.2-times higher mortality risk, emphasizing the need for prompt nutritional intervention 5