What are the recommended protein intake differences between chronic kidney disease (CKD) patients not on maintenance hemodialysis (MHD) and those on maintenance hemodialysis (MHD)?

Protein Intake Differences: CKD Not on Dialysis vs. Maintenance Hemodialysis

CKD patients not on dialysis should consume 0.55-0.60 g/kg/day (or up to 0.75-0.8 g/kg/day if unable to adhere to lower targets), while patients on maintenance hemodialysis require substantially higher intake at 1.0-1.2 g/kg/day to compensate for dialysis-related protein losses and maintain nutritional status. 1

CKD Stages 3-5 (Not on Dialysis)

Standard Protein Restriction

• Target: 0.55-0.60 g/kg/day for metabolically stable patients with CKD stages 3-5 who are at high risk of progression 1
• This can be achieved through either:
  • Low-protein diet providing 0.55-0.60 g/kg/day, OR
  • Very low-protein diet (0.28-0.43 g/kg/day) supplemented with ketoanalogue/amino acids to reach 0.55-0.60 g/kg/day total protein equivalents 1
• Alternative target: 0.6-0.75 g/kg/day for patients unable to maintain adequate energy intake on stricter restriction 1
• The most recent KDIGO 2024 guidelines recommend 0.8 g/kg/day as the simpler, preferred approach for most CKD stage 3-5 patients not at imminent risk of kidney failure 2

Special Populations (CKD Not on Dialysis)

• Diabetic CKD patients: 0.6-0.8 g/kg/day to maintain nutritional status while optimizing glycemic control 1, 3
• At least 50% should be high biological value protein in all non-dialysis CKD patients 1

Absolute Contraindications to Protein Restriction

• Metabolically unstable patients should never receive low-protein diets 2
• Children with CKD (growth impairment risk) 2
• Frail older adults with sarcopenia (require higher protein targets) 2, 3
• Hospitalized patients with acute illness 2

Maintenance Hemodialysis (MHD) Patients

Standard Protein Requirements

• Target: 1.0-1.2 g/kg/day for metabolically stable MHD patients 1, 4
• This represents a 2-fold increase compared to non-dialysis CKD patients 1
• At least 50% should be high biological value protein 1

Rationale for Higher Requirements

The substantially higher protein needs in MHD patients result from:

• Amino acid losses into dialysate: 6-12 g per hemodialysis session 1, 5
• Peptide and protein losses during dialysis 5
• Catabolic effects of uremic milieu, inflammatory state, oxidative stress, and bioincompatible dialysis materials 5
• Protein losses exceed those in peritoneal dialysis patients 1

Diabetic MHD Patients

• Same target: 1.0-1.2 g/kg/day 1
• Higher protein levels may be needed for patients at risk of hyper/hypoglycemia to maintain glycemic control 1

Acutely Ill MHD Patients

• Minimum: 1.2 g/kg/day during acute illness to prevent negative nitrogen balance 1
• Energy intake should be at least 35 kcal/kg/day for those <60 years, or 30-35 kcal/kg/day for those ≥60 years 1

Peritoneal Dialysis (PD) Patients

Standard Requirements

• Target: 1.0-1.2 g/kg/day (KDOQI 2020 recommendation) 1
• Older K/DOQI 2000 guidelines suggested 1.2-1.3 g/kg/day, with 1.3 g/kg/day increasing likelihood of adequate protein nutrition 1
• Peritoneal protein losses: 5-15 g/24 hours (higher during peritonitis) 1
• Amino acid losses: approximately 3 g/day 1

Energy Requirements Across All Groups

• CKD 1-5D and post-transplant: 25-35 kcal/kg/day based on age, sex, physical activity, body composition, and inflammation status 1
• MHD/PD patients <60 years: 35 kcal/kg/day 1
• MHD/PD patients ≥60 years: 30-35 kcal/kg/day (accounting for reduced activity) 1

Critical Implementation Points

Monitoring Requirements

• Nutritional assessment every 3 months: appetite, dietary intake, body weight, BMI, serum albumin 1, 4
• Biochemical monitoring: serum albumin, prealbumin, creatinine, urea 1
• Watch for protein-energy wasting: associated with increased mortality in both non-dialysis and dialysis populations 6

Common Pitfalls to Avoid

• Never restrict protein in dialysis patients — this is appropriate only for CKD 3-5 NOT on dialysis 4
• Avoid protein intake >1.3 g/kg/day in non-dialysis CKD patients at risk of progression 1, 3, 7
• Do not implement protein restriction without registered dietitian involvement to prevent malnutrition 2, 3
• Discontinue protein restriction during acute illness or hospitalization when requirements increase 2

Practical Algorithm for Protein Prescription

Step 1: Determine dialysis status

• Not on dialysis → proceed to Step 2
• On MHD or PD → prescribe 1.0-1.2 g/kg/day 1

Step 2: Assess metabolic stability (non-dialysis patients)

• Unstable, frail, sarcopenic, or child → contraindicated for restriction 2
• Stable → proceed to Step 3

Step 3: Assess diabetes status and adherence capacity

• Diabetic → prescribe 0.6-0.8 g/kg/day 1, 3
• Non-diabetic, high-risk, willing/able to adhere → consider 0.55-0.60 g/kg/day (with or without ketoanalogues) 1
• Non-diabetic, unable to adhere → prescribe 0.8 g/kg/day 2, 7

Step 4: Ensure dietitian referral and monitoring

• Mandatory for all protein-restricted patients 2, 3
• Monitor every 3 months minimum 1, 4

The evidence strongly supports this clear demarcation: non-dialysis CKD patients require protein restriction (0.55-0.8 g/kg/day) to slow progression, while dialysis patients require increased protein (1.0-1.2 g/kg/day) to compensate for dialysis losses and prevent malnutrition. 1, 5