[Management of malnutrition in chronic hemodialysis]

Malnutrition is an independent factor of morbidity and mortality in hemodialysis patients. Therefore, the nutritional management must be included in the follow-up and treatment of these patients. During hemodialysis, estimated nutritional requirements are 35-40 kcal/kg/day and 1.2-1.4 protein/kg/day. Dietary counseling, performed twice a year, makes it possible to detect the early signs of undernutrition. High risk malnutrition can be identified by the following indicators: normalized catabolic rate < 1 g/kg/j, serum albumin < 35 g/l, serum prealbumin < 300 mg/l. A trimestrial measurement of these variables is recommended. A schematic diagram is proposed for the nutritional management of malnourished hemodialysis patient. The occurrence of malnutrition implies to look for any cause of anorexia or hypercatabolism such as inadequate nutritional intakes, inadequate dialysis, severe anemia and depression. Nutritional supplementation must be adapted according to its ability to satisfy nutritional needs: oral supplements in patients with beginning undernutrition; intradialytic parental nutrition in patients with severe malnutrition and spontaneous intakes more than 20 kcal/kg/day; daily enteral nutrition when spontaneous intakes are less than 20 kcal/kg/day.