Can Preprotein Be Administered to Patients with HD?
Yes, protein supplementation can and should be administered to hemodialysis patients, particularly those with evidence of malnutrition or inadequate dietary intake, with a target dietary protein intake of 1.0-1.2 g/kg body weight per day. 1
Protein Requirements for Hemodialysis Patients
Hemodialysis patients require higher protein intake than the general population due to dialysis-related protein losses and increased catabolism. The evidence consistently supports this approach:
- The 2020 KDOQI guidelines recommend prescribing 1.0-1.2 g/kg body weight per day of dietary protein for metabolically stable adults on maintenance hemodialysis to maintain stable nutritional status. 1
- This recommendation applies to both diabetic and non-diabetic HD patients, though diabetic patients may require higher protein intake to maintain glycemic control. 1
- Each hemodialysis session removes approximately 10-12 grams of amino acids, necessitating higher dietary protein intake to compensate for these losses. 1
When Protein Supplementation Is Indicated
Oral protein-energy supplementation should be provided when patients cannot meet 70% of their protein requirements through regular diet alone:
- Patients at risk of or with protein-energy wasting should receive oral nutritional supplements (ONS). 1
- Evidence from multiple RCTs demonstrates that ONS improves serum albumin, transthyretin (prealbumin), and survival rates in malnourished hemodialysis patients. 1
- The increase in transthyretin during ONS is independently associated with better survival, regardless of inflammatory status. 1
Monitoring Nutritional Status
Use serum prealbumin (transthyretin) levels ≥30 mg/dL as a target when monitoring nutritional status in HD patients. 1
- Low predialysis serum creatinine (<10 mg/dL) suggests decreased skeletal muscle mass and/or low dietary protein intake, warranting evaluation for protein-energy malnutrition. 1
- Serum creatinine and creatinine index are valid markers of protein-energy nutritional status and predict mortality in HD patients. 1
Special Considerations for Acutely Ill HD Patients
For hospitalized or acutely ill hemodialysis patients, protein requirements increase to 1.2-1.3 g/kg/d or higher:
- Acutely ill hospitalized HD patients often ingest less than recommended amounts and are usually in negative nitrogen balance. 1
- Protein intakes of 1.3 g/kg/d or greater with adequate energy intake (30-35 kcal/kg/d) improve biochemical markers of nutritional status in hospitalized dialysis patients. 1
- Patients receiving more intensive dialysis (>3 times per week or continuous venovenous hemofiltration) may tolerate and require protein intakes exceeding 1.3 g/kg/d due to increased amino acid losses. 1
Alternative Routes When Oral Intake Is Inadequate
When oral intake fails to meet requirements despite counseling and ONS, consider intradialytic parenteral nutrition (IDPN):
- IDPN is specifically indicated for malnourished HD patients who fail to respond to or cannot tolerate oral nutritional supplements or enteral nutrition. 1
- Multiple RCTs show nutritional improvements with IDPN in HD patients with overt protein-energy wasting. 1
- IDPN should not be used as first-line therapy before attempting dietary counseling and ONS. 1
Critical Pitfalls to Avoid
- Do not restrict protein in hemodialysis patients—this is appropriate only for CKD stages 3-5 not yet on dialysis (0.55-0.60 g/kg/d). 1
- Inadequate protein intake (<1.0 g/kg/d) in HD patients is associated with increased mortality, hypoalbuminemia, and prolonged hospital stays. 1
- Energy intake must be adequate (25-35 kcal/kg/d) for protein supplementation to be effective; protein alone without sufficient calories leads to protein catabolism for energy. 1
- In diabetic HD patients with hypertension, monitor for hypoglycemia when increasing protein intake, as improved nutritional status may alter insulin requirements. 1