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India ranks as the No 1 nation in the world for diabetic population. Consequently the number of people losing their kidneys because of diabetes & hypertension- a deadly combination is ever increasing. Irony is, on the name of medical care we have opened no of Dialysis units in each city, but the Nutrition management of those patients is still poor and no of days of a dialysis patient is already counted today. But this situation is not because of lack of availability of the medical treatment or nutritionists, but because of the Poor Nutritional Management or ignorance about proper MNT for ESRD.

The advent of CKD and progression to ESRD is associated with huge imbalances of metabolic processes in the body. These alterations in the metabolic processes occur in very short span of months or few yrs. Most sought after treatment is HAEMODIALYSIS. Haemodialysis is a process involving:

Above mechanism involves exchange of selectively permeable molecules across the dialysis membrane. Urea and creatinine molecules are exchanged with glucose molecules. But Dialysis acts as a drain to the body proteins and daily losses can occur to an extent of 20 to 30 g in 24 hrs continuous peritoneal dialysis = 1 g / hr.

In ESRD physiological and metabolic alterations demand a highly specialized MNT to:
Maintain Serum albumin levels High protein diet (1.2 – 1.5 gm/kg/day)
Prevent loss of lean body mass 75% of total protein of HBV (Albumen)
Minimize the rate of nitrogenous HBV- 75% of total protein, waste production
Maintain the electrolyte balance Low sodium, low potassium diet
Maintain water balance Measured fluids per day
Maintain the blood pressure Low sodium, measure fluids per day
Maintain bone health Low phosphorous, high calcium diet


    Protein–calorie malnutrition is the most common nutritional deficiency in dialysis population. Mild to moderate in 33% of patients, Severe in 6% to 8% The major causes of malnutrition are:
  • Low Nutrient Intake,
  • Superimposed Illness,
  • Dialytic Procedure
  • Dialysis promotes wasting by removing nutrients, including AA.
  • HD with
  • PAN resulted in more AA losses/session (6.1±2.3 g)
  • PS (3.8±1.3 g)
  • CUP (3.7±1.3 g).
  • Losses of EAA and NEAA with PAN were greater than with CUP by approximately 100% and 50% respectively


    Nephrol Dial Transplant, (1998): 13; 113-117
  • Nutritional surveys have shown that protein–energy malnutrition may be assessed from plasma AA, and that the earliest indication of malnutrition may be a low concentration of plasma EAA, particularly valine. It is possible that this lower serum valine could be an early marker of an alteration in the nutritional state.
  • Important attention must be paid to the level of BCAA, which, are precursors for the synthesis of proteins and fatty acids, regulators of protein turnover, insulin release and skeletal muscle energy metabolism
  • In agreement with recent reports [6] we found that losses of BCAA are similar with PS and CUP, However, our study shows that dialysis with PAN results in higher BCAA losses.

Nephrol Dial Transplant, (1998): 13; 113-117 COMPLICATIONS OF HYPOPROTEINEMIA:

    Mortality and morbidity in haemodialysis patients remain high in spite of great improvements in technology that one would expect to improve patient survival. Three main topics that can influence patient outcome and well-being:
  • The dialysis dose,
  • Nutrition,
  • Biocompatibility of the dialysis procedure.

Blood Purification 1999;17:159-165

Hypoalbuminemia, a major adverse prognostic factor In dialysis patients, is strongly associated with cardiac disease.

J. Am. Soc. Nephrol. 1996; 7:728-73#{243

Hypoalbuminemia is an important risk factor of hypotension during hemodialysis

Hemodialysis International Volume 10 Issue s2 Page S10-S15, October 2006

Hypoalbuminemia as a Risk Factor for Progressive Left-Ventricular Hypertrophy in Hemodialysis Patients

American Journal of Nephrology 2000;20:396-401

Diabetes mellitus, Lymphopenia, Hpoalbuminemia were the strongest predictive factors for mortality and technique failure on CAPD. (12-year CAPD program is one of the largest single-centers reported in CAPD literature. )