Is Glucerna (glucose-based oral nutritional supplement) a suitable supplement for a patient with impaired renal function on dialysis?

Glucerna Is Not Recommended for Dialysis Patients

Glucerna is not an appropriate supplement for renal patients on dialysis because it is not formulated to meet the specific nutritional requirements of dialysis patients, particularly regarding protein content, electrolyte composition, and phosphorus levels.

Why Glucerna Is Inappropriate for Dialysis Patients

Protein Requirements Are Not Met

• Dialysis patients require 1.2-1.3 g/kg/day of protein, with at least 50% from high biological value sources 1, 2, 3
• Each hemodialysis session removes approximately 10-12 grams of amino acids, creating substantial ongoing losses that must be replaced 3
• Glucerna is designed for diabetic patients without kidney disease and contains insufficient protein to meet dialysis requirements 1

Electrolyte and Mineral Concerns

• Dialysis patients require strict phosphorus restriction to prevent hyperphosphatemia, which is a major concern 1
• Standard diabetic formulas like Glucerna are not designed with the electrolyte restrictions (potassium, phosphorus) necessary for dialysis patients 1
• Renal-specific formulas are specifically designed with controlled electrolyte content appropriate for kidney failure 4

What Should Be Used Instead

Renal-Specific Oral Nutritional Supplements

• Renal-specific supplements (such as Nepro, Suplena, or similar products) are specifically formulated for dialysis patients with appropriate protein, electrolyte, and phosphorus content 4
• A recent randomized trial demonstrated that renal-specific ONS improved malnutrition inflammation scores by 29% and serum albumin by 5.3% in hemodialysis patients over 30 days 4

Oral Nutritional Supplementation Strategy

• Oral nutritional supplements should be the first-line intervention for malnourished dialysis patients who cannot meet requirements through diet alone 1
• ONS can add 10-12 kcal/kg and 0.3-0.5 g protein/kg daily when provided twice daily at least 1 hour after meals 1
• Intradialytic nutrition (providing supplements during hemodialysis sessions) has been shown to improve serum albumin, transthyretin, and subjective global assessment scores 1, 5

Energy Requirements

• Target energy intake should be 35 kcal/kg/day for patients <60 years and 30-35 kcal/kg/day for patients ≥60 years 1, 2, 3
• Adequate energy intake is essential to prevent protein from being catabolized for energy 3

Special Considerations for Diabetic Dialysis Patients

Glycemic Control Challenges

• HbA1c is less reliable in dialysis patients due to decreased red blood cell lifespan and anemia 6
• Target more moderate fasting glucose levels of 110-130 mg/dL rather than aggressive targets, as very low HbA1c is associated with increased mortality in hemodialysis patients 6
• Continuous glucose monitoring is preferred over HbA1c for glycemic assessment in dialysis patients 6

Insulin Requirements Change Dramatically

• Patients transitioning to dialysis typically require 50% reduction in total daily insulin dose for type 2 diabetes 6
• Insulin clearance is reduced and insulin action is prolonged in dialysis patients 6
• Hypoglycemia during dialysis is extremely common, occurring in 46-52% of diabetic patients on maintenance hemodialysis 6

Common Pitfalls to Avoid

• Do not use standard diabetic formulas (like Glucerna) designed for non-renal patients, as they lack appropriate electrolyte restrictions and protein content 1, 4
• Do not rely solely on dietary counseling without supplementation in malnourished dialysis patients—ONS combined with dietary advice is superior to counseling alone 4
• Do not delay nutritional intervention—the period after which nutritional support should be instituted ranges from days to 2 weeks depending on clinical condition 1
• Monitor for hypophosphatemia during refeeding with any nutritional supplement, as this can occur even with renal-specific formulas 1

Monitoring Parameters

• Serum albumin every 1-4 months with target in normal range 2, 3
• Normalized protein nitrogen appearance (nPNA) ≥0.9 g/kg/day 2, 3
• Body weight monitoring to prevent >10% loss over 6 months 2
• Serum phosphorus, potassium, and calcium levels require regular monitoring when using any nutritional supplement 1