Malnutrition in patients with chronic kidney disease


Malnutrition is a major issue in patients with chronic kidney disease (CKD), adversely affecting morbidity, mortality, functional activity and patients’ quality of life. Our knowledge of the pathogenic mechanisms of malnutrition in patients with CKD, including endstage renal disease, has been improved. This has led to the development of clinical practice guidelines for nutritional care in CKD which provide a framework for the nutritional issues facing patients and physiccians. Extensive research in the field of nutrition in patients with CKD has resulted in the formation of general guidelines, although some uncertainties still exist on some of the best therapeutic or preventive options in uremic malnutrition. It is important to search actively for malnutrition since early diagnosis and treatment can improve the prognosis for CKD patients and reduce the monetary costs connected with treatment.

Share and Cite:

Chung, S. , Koh, E. , Shin, S. and Park, C. (2012) Malnutrition in patients with chronic kidney disease. Open Journal of Internal Medicine, 2, 89-99. doi: 10.4236/ojim.2012.22018.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Snyder, S. and Pendergraph, B. (2005) Detection and evaluation of chronic kidney disease. American Family Physician, 72, 1723-1732.
[2] Stevens, P.E., O’Donoghue, D.J., De Lusignan, S., et al. (2007) Chronic kidney disease management in the United Kingdom: NEOERICA project results. Kidney International, 72, 92-99. doi:10.1038/
[3] Chin, H.J. and Kim, S. (2009) Chronic kidney disease in Korea. The Korean Journal Medine, 76, 511-514.
[4] Cibulka, R. and Racek, J. (2007) Metabolic disorders in patients with chronic kidney failure. Physiological Research, 56, 697-705.
[5] Levey, A.S., Eckardt, K.U., Tsukamoto, Y., et al. (2005) Definition and classification of chronic kidney disease: A position statement from kidney disease: Improving global outcomes (KDIGO). Kidney International, 67, 2089-2100. doi:10.1111/j.1523-1755.2005.00365.x
[6] Zhang, Q.L. and Rothenbacher, D. (2008) Prevalence of chronic kidney disease in population-based studies: Systematic review. BMC Public Health, 8, 117. doi:10.1186/1471-2458-8-117
[7] Pupim, L.B., Cuppari, L. and Ikizler, T.A. (2006) Nutrition and metabolism in kidney disease. Seminars in Nephrology, 26, 134-157. doi:10.1016/j.semnephrol.2005.09.010
[8] Stenvinkel, P., Heimbürger, O., Paultre, F., et al. (1999) Strong association between malnutrition, inflammation, and atherosclerosis in chronic renal failure. Kidney International, 55, 1899-1911. doi:10.1046/j.1523-1755.1999.00422.x
[9] Savica, V., Santoro, D., Ciolino, F., et al. (2005) Nutritional therapy in chronic kidney disease. Nutrition in Clinical Care, 8, 70-76.
[10] Krebs, H.A. (1963) Renal gluconeogenesis. Advances in Enzyme Regulation, 1, 385-400. doi:10.1016/0065-2571(63)90034-7
[11] Cersosimo, E., Garlick, P. and Ferretti J. (1999) Insulin regulation of renal glucose metabolism in humans. American Journal of Physiology, 276, E78-E84.
[12] Cersosimo, E., Garlick, P. and Ferretti J. (1999) Renal glucose production during insulin-induced hypoglycemia in humans. Diabetes, 48, 261-266. doi:10.2337/diabetes.48.2.261
[13] Cersosimo, E., Garlick P. and Ferretti J. (2000) Renal substrate metabolism and gluconeogenesis during hypoglycemia in humans. Diabetes, 49, 1186-1193. doi:10.2337/diabetes.49.7.1186
[14] Meyer, C., Stumvoll, M., Dostou, J., et al. (2002) Renal substrate exchange and gluconeogenesis in normal postabsorptive humans. American Journal of Physiology, Endocrinology and Metabolism, 282, E428-E434.
[15] Fouque, D., Kalantar-Zadeh, K., Kopple, J., et al. (2008) A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney International, 73, 391-398. doi:10.1038/
[16] Fleet, M., Osman, F., Komaragiri, R., et al. (2008) Protein catabolism in advanced renal disease: Role of cytokines. Clinical Nephrology, 70, 91-100.
[17] Ikizler, T.A. (2004) Protein and energy: Recommended intake and nutrient supplementation in chronic dialysis patients. Seminars in Dialysis, 17, 471-478. doi:10.1111/j.0894-0959.2004.17608.x
[18] Kovacic, V., Roguljic, L. and Kovacic, V. (2003) Metabolic acidosis of chronically hemodialyzed patients. American Journal of Nephrology, 23, 158-164. doi:10.1159/000070205
[19] Mehrotra, R., Kopple, J.D. and Wolfson, M. (2003) Metabolic acidosis in maintenance dialysis patients: Clinical considerations. Kidney International Supplement, 88, S13-S25. doi:10.1046/j.1523-1755.2003.08802.x
[20] Lee, P.D., Conover, C.A. and Powell, D.R. (1993) Regulation and function of insulin-like growth factor-binding protein-1. Proceedings of the Society for Experimental Biology and Medicine, 204, 4-29.
[21] Alvestrand, A. (1997) Carbohydrate and insulin metabolism in renal failure. Kidney International Supplement, 62, S48-S52.
[22] Rigalleau, V. and Gin, H. (2005) Carbohydrate metabolism in uraemia. Current Opinion in Clinical Nutrition and Metabolic Care, 8, 463-469. doi:10.1097/01.mco.0000172590.32564.b9
[23] Ikizler, T.A. (2008) Nutrition, inflammation and chronic kidney disease. Current Opinion in Nephrology and Hypertension, 17, 162-167. doi:10.1097/MNH.0b013e3282f5dbce
[24] Attman, P.O., Samuelsson, O. and Alaupovic, P. (1993) Lipoprotein metabolism and renal failure. American Journal of Kidney Diseases, 21, 573-592.
[25] Guarnieri, G., Fonda, M., Situlin, R., et al. (1992) Effects of L-carnitine supplementation in the dialysate on serum lipoprotein composition of hemodialysis patients. Contributions to Nephrology, 98, 36-43.
[26] Kalantar-Zadeh, K., Ikizler, T.A., Block, G., et al. (2003) Malnutrition-inflammation complex syndrome in dialysis patients: Causes and consequences. American Journal of Kidney Diseases, 42, 864-881. doi:10.1016/j.ajkd.2003.07.016
[27] Kalantar-Zadeh, K., Stenvinkel, P., Bross, R., et al. (2005) Kidney insufficiency and nutrient-based modulation of inflammation. Current Opinion in Clinical Nutrition and Metabolic Care, 8, 388-396. doi:10.1097/01.mco.0000172578.56396.9e
[28] Garibotto, G., Sofia, A., Balbi, M., et al. (2007) Kidney and splanchnic handling of interleukin-6 in humans. Cytokine, 37, 51-54. doi:10.1016/j.cyto.2007.02.015
[29] Tsujinaka, T., Fujita, J., Ebisui, C., et al. (1996) Interleukin 6 receptor antibody inhibits muscle atrophy and modulates proteolytic systems in interleukin 6 transgenic mice. The Journal of Clinical Investigation, 97, 244-249. doi:10.1172/JCI118398
[30] K?nner, A.C., Kl?ckener, T. and Brüning, J.C. (2009) Control of energy homeostasis by insulin and leptin: Targeting the arcuate nucleus and beyond. Physiology & Behavior, 97, 632-638. doi:10.1016/j.physbeh.2009.03.027
[31] Garibotto, G., Russo, R., Franceschini, R., et al. (1998) Inter-organ leptin exchange in humans. Biochemical and Biophysical Research Communications, 247, 504-509. doi:10.1006/bbrc.1998.8819
[32] Kalantar-Zadeh, K., Stenvinkel, P., Pillon, L., et al. (2003) Inflammation and nutrition in renal insufficiency. Advances in Renal Replacement Therapy, 10, 155-169. doi:10.1053/j.arrt.2003.08.008
[33] Franch, H.A. and Mitch, W.E. (2009) Navigating between the Scylla and Charybdis of prescribing dietary protein for chronic kidney diseases. Annual Review of Nutrition, 29, 341-64. doi:10.1146/annurev-nutr-080508-141051
[34] Galli, F. (2007) Protein damage and inflammation in uraemia and dialysis patients. Nephrology Dialysis Transplantation, 22, v20-v36. doi:10.1093/ndt/gfm294
[35] Roubenoff, R., Roubenoff, R.A., Cannon, J.G., et al. (1994) Rheumatoid cachexia: Cytokine-driven hypermetabolism accompanying reduced body cell mass in chronic inflammation. The Journal of Clinical Investigation, 93, 2379-2386. doi:10.1172/JCI117244
[36] Neyra, R., Chen, K.Y., Sun, M., et al. (2003) Increased resting energy expenditure in patients with end-stage renal disease. JPEN Journal of Parenteral and Enteral Nutrition, 27, 36-42. doi:10.1177/014860710302700136
[37] Borah, M.F., Schoenfeld, P.Y., Gotch, F.A., et al. (1978) Nitrogen balance during intermittent dialysis therapy of uremia. Kidney International, 14, 491-500. doi:10.1038/ki.1978.154
[38] Klaunig, J.E., Xu, Y., Isenberg, J.S., et al. (1998) The role of oxidative stress in chemical carcinogenesis. Environmental Health Perspectives, 106, 289-295.
[39] Lim, P.S., Wei, Y.H., Yu, Y.L., et al. (1999) Enhanced oxidative stress in haemodialysis patients receiving intravenous iron therapy. Nephrology Dialysis Transplantation, 14, 2680-2687. doi:10.1093/ndt/14.11.2680
[40] Chan, W., Valerie, K.C. and Chan, J.C. (1993) Expression of insulin-like growth factor-1 in uremic rats: Growth hormone resistance and nutritional intake. Kidney International, 43, 790-795. doi:10.1038/ki.1993.112
[41] Schaefer, F., Chen, Y., Tsao, T., et al. (2001) Impaired JAK-STAT signal transduction contributes to growth hormone resistance in chronic uremia. The Journal of Clinical Investigation, 108, 467-475.
[42] Brüngger, M., Hulter, H.N. and Krapf, R. (1997) Effect of chronic metabolic acidosis on the growth hormone/ IGF-1 endocrine axis: New cause of growth hormone insensitivity in humans. Kidney International, 51, 216-221. doi:10.1038/ki.1997.26
[43] Kraut, J.A. and Kurtz, I. (2005) Metabolic acidosis of CKD: Diagnosis, clinical characteristics, and treatment. American Journal of Kidney Diseases, 45, 978-993. doi:10.1053/j.ajkd.2005.03.003
[44] Oh, M.S., Uribarri, J., Weinstein, J., et al. (2004) What unique acid-base considerations exist in dialysis patients? Seminars in Dialysis, 17, 351-364. doi:10.1111/j.0894-0959.2004.17342.x
[45] Garibotto, G., Russo, R., Sofia, A., et al. (1994) Skeletal muscle protein synthesis and degradation in patients with chronic renal failure. Kidney International, 45, 1432-1439. doi:10.1038/ki.1994.187
[46] Pollock, C.A., Ibels, L.S., Zhu, F.Y., et al. (1997) Protein intake in renal disease. Journal of the American Society of Nephrology, 8, 777-783. doi:10.1038/ki.1994.187
[47] Pupim, L.B., Kent, P., Caglar, K., et al. (2002) Improvement in nutritional parameters after initiation of chronic hemodialysis. American Journal of Kidney Diseases, 40, 143-151. doi:10.1053/ajkd.2002.33923
[48] Bossola, M., Muscaritoli, M., Tazza, L., et al. (2005) Malnutrition in hemodialysis patients: What therapy? American Journal of Kidney Diseases, 46, 371-386. doi:10.1053/j.ajkd.2005.05.031
[49] Ikizler, T.A., Pupim, L.B., Brouillette, J.R., et al. (2002) Hemodialysis stimulates muscle and whole body protein loss and alters substrate oxidation. American Journal of Physiology, Endocrinology and Metabolism, 282, E107-E116.
[50] Parker, T.F. III., Wingard, R.L., Husni, L., et al. (1996) Effect of the membrane biocompatibility on nutritional parameters in chronic hemodialysis patients. Kidney International, 49, 551-556. doi:10.1038/ki.1996.78
[51] Pupim, L.B. and Ikizler, T.A. (2003) Uremic malnutrition: New insights into an old problem. Seminars in Dialysis, 16, 224-232. doi:10.1046/j.1525-139X.2003.16046.x
[52] Ikizler, T.A., Wingard, R.L., Sun, M., et al. (1996) Increased energy expenditure in hemodialysis patients. Journal of the American Society of Nephrology, 7, 2646-2653.
[53] Kaysen, G.A. and Levin, N.W. (2002) Why measure serum albumin levels? Journal of Renal Nutrition, 12, 148-150. doi:10.1053/jren.2002.33509
[54] Kaysen, G.A., Dubin, J.A., Müller, H.G., et al. (2002) Relationships among inflammation nutrition and physicologic mechanisms establishing albumin levels in hemodialysis patients. Kidney International, 61, 2240-2249. doi:10.1046/j.1523-1755.2002.00076.x
[55] Kaysen, G.A., Stevenson, F.T. and Depner, T.A. (1997) Determinants of albumin concentration in hemodialysis patients. American Journal of Kidney Diseases, 29, 658-668. doi:10.1016/S0272-6386(97)90117-7
[56] Kaysen, G.A., Rathore, V., Shearer, G.C., et al. (1995) Mechanisms of hypoalbuminemia in hemodialysis patients. Kidney International, 48, 510-516. doi:10.1038/ki.1995.321
[57] Neyra, N.R., Hakim, R.M., Shyr, Y., et al. (2000) Serum transferrin and serum prealbumin are early predictors of serum albumin in chronic hemodialysis patients. Journal of Renal Nutrition, 10, 184-190. doi:10.1053/jren.2000.16325
[58] Chertow, G.M., Ackert, K., Lew, N.L., et al. (2000) Prealbumin is as important as albumin in the nutritional assessment of hemodialysis patients. Kidney International, 58, 2512-2517. doi:10.1046/j.1523-1755.2000.00435.x
[59] Holland, D.C., Meers, C., Lawlor, M.E., et al. (2001) Serial prealbumin levels as predictors of outcomes in a retrospective cohort of peritoneal and hemodialysis patients. Journal of Renal Nutrition, 11, 129-138. doi:10.1053/jren.2001.24358
[60] Suliman, M.E., Lindholm, B., Bárány, P., et al. (2001) Hyperhomocysteinemia in chronic renal failure patients: Relation to nutritional status and cardiovascular disease. Clinical Chemistry and Laboratory Medicine, 39, 734-738. doi:10.1515/CCLM.2001.122
[61] Perna, A.F., Ingrosso, D., Satta, E., et al. (2004) Homocysteine metabolism in renal failure. Current Opinion in Clinical Nnutrition and Metabolic Care, 7, 53-57. doi:10.1097/00075197-200401000-00010
[62] Kerr, P.G., Strauss, B.J. and Atkins, R.C. (1996) Assessment of the nutritional state of dialysis patients. Blood Purification, 14, 382-387. doi:10.1159/000170290
[63] Chertow, G.M., Lazarus, J.M., Lew, N.L., et al. (1997) Bioimpedance norms for the hemodialysis population. Kidney International, 52, 1617-1621. doi:10.1038/ki.1997.493
[64] Detsky, A.S., McLaughlin, J.R., Baker, J.P., et al. (1987) What is subjective global assessment of nutritional status? JPEN Journal of Parenteral and Enteral Nutrition, 11, 8-13. doi:10.1177/014860718701100108
[65] Cooper, B.A., Bartlett, L.H., Aslani, A., et al. (2002) Validity of subjective global assessment as a nutritional marker in end-stage renal disease. American Journal of Kidney Diseases, 40, 126-132. doi:10.1053/ajkd.2002.33921
[66] Papadoyannakis, N.J., Stefanidis, C.J. and McGeown, M. (1984) The effect of the correction of metabolic acidosis on nitrogen and potassium balance of patients with chronic renal failure. The American Journal of Clinical Nutrition, 40, 623-627.
[67] Price, S.R. and Mitch, W.E. (1994) Metabolic acidosis and uremic toxicity: Protein and amino acid metabolism. Seminars in Nephrology, 14, 232-237.
[68] Eustace, J.A., Coresh, J., Kutchey, C., et al. (2000) Randomized double-blind trial of oral essential amino acids for dialysis-associated hypoalbuminemia. Kidney International, 57, 2527-2538. doi:10.1046/j.1523-1755.2000.00112.x
[69] Caglar, K., Fedje, L., Dimmitt, R., et al. (2002) Therapeutic effects of oral nutritional supplementation during hemodialysis. Kidney International, 62, 1054-1059. doi:10.1046/j.1523-1755.2002.00530.x
[70] Burrowes, J.D., Bluestone, P.A., Wang, J., et al. (1999) The effects of moderate doses of megestrol acetate on nutritional status and body composition in a hemodialysis patient. Journal of Renal Nutrition, 9, 89-94. doi:10.1016/S1051-2276(99)90006-7
[71] Kotzmann, H., Yilmaz, N., Lercher, P., et al. (2001) Differential effects of growth hormone therapy in malnourished hemodialysis patients. Kidney International, 60, 1578-1585. doi:10.1046/j.1523-1755.2001.00971.x
[72] Hammerman, M.R. (2000) Insulin-like growth factor I treatment for end-stage renal disease at the end of the millennium. Current Opinion in Nephrology and Hypertension, 9, 1-3. doi:10.1097/00041552-200001000-00001
[73] Bossola, M., Muscaritoli, M., Tazza, L., et al. (2005) Malnutrition in hemodialysis patients: What therapy? American Journal of Kidney Diseases, 46, 371-386. doi:10.1053/j.ajkd.2005.05.031
[74] Pupim, L.B., Flakoll, P.J., Brouillette, J.R., et al. (2002) Intradialytic parenteral nutrition improves protein and energy homeostasis in chronic hemodialysis patients. The Journal of Clinical Investigation, 110, 483-492.
[75] Jones, M., Hagen, T., Boyle, C.A., et al. (1998) Treatment of malnutrition with 1.1% amino acid peritoneal dialysis solution: Results of a multicenter outpatient study. American Journal of Kidney Diseases, 32, 761-769. doi:10.1016/S0272-6386(98)70131-3
[76] Mak, R.H. and Cheung, W. (2007) Therapeutic strategy for cachexia in chronic kidney disease. Current Opinion in Nephrology and Hypertension, 16, 542-546. doi:10.1097/MNH.0b013e3282f02204

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.