Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Assessment of nutritional status in end-stage renal disease

Marsha Wolfson, MD, FACP
Section Editor
Steve J Schwab, MD
Deputy Editor
Alice M Sheridan, MD


Depending in part upon the method used and the population studied, from 40 to 70 percent of patients with end-stage renal disease (ESRD) are malnourished [1-10], a complication that appears to be associated with increased mortality [8,9]. (See "Patient survival and maintenance dialysis", section on 'Malnutrition'.)

As a result of the frequency of malnutrition, periodic assessment of nutritional status should be part of the routine care of dialysis patients to permit early recognition and the institution of appropriate therapy (table 1). Most of the standard methods of assessing nutritional status can be applied to patients with renal failure; however, some of these parameters are altered by uremia. It is therefore helpful to review briefly the characteristics of the different tests that are used.


There is no single measurement that can be used to determine the presence of malnutrition [11]. Therefore, a panel of measurements is recommended, including measures of body mass (body mass index [BMI]) and composition, a measure of dietary protein and energy intake, and at least one measure of serum protein status (table 2) [12].

History and physical examination — The history and physical examination can often provide important clues to the patient who might be malnourished. These include:

Symptoms such as nausea, vomiting, anorexia, or weight loss or gain. Large interdialytic weight gain is discouraged because it is thought to reflect excessive fluid and sodium intake. In some cases, however, over time, increased body weight gain may represent improved nutritional status [13]. A careful assessment should be performed to distinguish between these possibilities.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Nov 14, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Thunberg BJ, Swamy AP, Cestero RV. Cross-sectional and longitudinal nutritional measurements in maintenance hemodialysis patients. Am J Clin Nutr 1981; 34:2005.
  2. Wolfson M, Strong CJ, Minturn D, et al. Nutritional status and lymphocyte function in maintenance hemodialysis patients. Am J Clin Nutr 1984; 39:547.
  3. Schoenfeld PY, Henry RR, Laird NM, Roxe DM. Assessment of nutritional status of the National Cooperative Dialysis Study population. Kidney Int Suppl 1983; :S80.
  4. Keshaviah PR, Nolph KD, Moore HL, et al. Lean body mass estimation by creatinine kinetics. J Am Soc Nephrol 1994; 4:1475.
  5. Marckmann P. Nutritional status of patients on hemodialysis and peritoneal dialysis. Clin Nephrol 1988; 29:75.
  6. Buchwald R, Peña JC. Evaluation of nutritional status in patients on continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1989; 9:295.
  7. Young GA, Kopple JD, Lindholm B, et al. Nutritional assessment of continuous ambulatory peritoneal dialysis patients: an international study. Am J Kidney Dis 1991; 17:462.
  8. Owen WF Jr, Lew NL, Liu Y, et al. The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis. N Engl J Med 1993; 329:1001.
  9. Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990; 15:458.
  10. Aparicio M, Cano N, Chauveau P, et al. Nutritional status of haemodialysis patients: a French national cooperative study. French Study Group for Nutrition in Dialysis. Nephrol Dial Transplant 1999; 14:1679.
  11. Tattersall J, Martin-Malo A, Pedrini L, et al. EBPG guideline on dialysis strategies. Nephrol Dial Transplant 2007; 22 Suppl 2:ii5.
  12. Fouque D, Pelletier S, Mafra D, Chauveau P. Nutrition and chronic kidney disease. Kidney Int 2011; 80:348.
  13. Testa A, Beaud JM. The other side of the coin: interdialytic weight gain as an index of good nutrition. Am J Kidney Dis 1998; 31:830.
  14. Dialysis Outcomes Quality Initiative Guidelines. Clinical practice guidelines for nutrition in chronic renal failure. I. Adult guidelines A. Maintenance dialysis. Am J Kidney Dis 2000; 35(Suppl 2):S19.
  15. Wolfson M. Management of protein and energy intake in dialysis patients. J Am Soc Nephrol 1999; 10:2244.
  16. Hakim RM, Levin N. Malnutrition in hemodialysis patients. Am J Kidney Dis 1993; 21:125.
  17. Nelson EE, Hong CD, Pesce AL, et al. Anthropometric norms for the dialysis population. Am J Kidney Dis 1990; 16:32.
  18. VanItallie TB, Yang MU, Heymsfield SB, et al. Height-normalized indices of the body's fat-free mass and fat mass: potentially useful indicators of nutritional status. Am J Clin Nutr 1990; 52:953.
  19. Segal KR, Burastero S, Chun A, et al. Estimation of extracellular and total body water by multiple-frequency bioelectrical-impedance measurement. Am J Clin Nutr 1991; 54:26.
  20. Heymsfield SB, Smith R, Aulet M, et al. Appendicular skeletal muscle mass: measurement by dual-photon absorptiometry. Am J Clin Nutr 1990; 52:214.
  21. Isoyama N, Qureshi AR, Avesani CM, et al. Comparative associations of muscle mass and muscle strength with mortality in dialysis patients. Clin J Am Soc Nephrol 2014; 9:1720.
  22. Stall SH, Ginsberg NS, DeVita MV, et al. Comparison of five body-composition methods in peritoneal dialysis patients. Am J Clin Nutr 1996; 64:125.
  23. Mafra D, Deleaval P, Teta D, et al. Influence of inflammation on total energy expenditure in hemodialysis patients. J Ren Nutr 2011; 21:387.
  24. Goldwasser P, Mittman N, Antignani A, et al. Predictors of mortality in hemodialysis patients. J Am Soc Nephrol 1993; 3:1613.
  25. Teehan BP, Schleifer CR, Brown JM, et al. Urea kinetic analysis and clinical outcome on CAPD. A five year longitudinal study. Adv Perit Dial 1990; 6:181.
  26. Rocco MV, Jordan JR, Burkart JM. The efficacy number as a predictor of morbidity and mortality in peritoneal dialysis patients. J Am Soc Nephrol 1993; 4:1184.
  27. Gama-Axelsson T, Heimbürger O, Stenvinkel P, et al. Serum albumin as predictor of nutritional status in patients with ESRD. Clin J Am Soc Nephrol 2012; 7:1446.
  28. Kaysen GA, Rathore V, Shearer GC, Depner TA. Mechanisms of hypoalbuminemia in hemodialysis patients. Kidney Int 1995; 48:510.
  29. Rocco MV, Dwyer JT, Larive B, et al. The effect of dialysis dose and membrane flux on nutritional parameters in hemodialysis patients: results of the HEMO Study. Kidney Int 2004; 65:2321.
  30. Tayeb JS, Provenzano R, El-Ghoroury M, et al. Effect of biocompatibility of hemodialysis membranes on serum albumin levels. Am J Kidney Dis 2000; 35:606.
  31. US Renal Data System. USRDS 2009 Annual Data Report. ESRD clinical performance measures project. Am J Kidney Dis 2010; 55(Suppl 1):S1.
  32. Kopple JD, Swendseid ME. Vitamin nutrition in patients undergoing maintenance hemodialysis. Kidney Int Suppl 1975; :79.
  33. Chertow GM, Ackert K, Lew NL, et al. Prealbumin is as important as albumin in the nutritional assessment of hemodialysis patients. Kidney Int 2000; 58:2512.
  34. Cano N, Di Costanzo-Dufetel J, Calaf R, et al. Prealbumin-retinol-binding-protein-retinol complex in hemodialysis patients. Am J Clin Nutr 1988; 47:664.
  35. Chertow GM, Goldstein-Fuchs DJ, Lazarus JM, Kaysen GA. Prealbumin, mortality, and cause-specific hospitalization in hemodialysis patients. Kidney Int 2005; 68:2794.
  36. Bergström J, Alvestrand A, Fürst P. Plasma and muscle free amino acids in maintenance hemodialysis patients without protein malnutrition. Kidney Int 1990; 38:108.
  37. Degoulet P, Legrain M, Réach I, et al. Mortality risk factors in patients treated by chronic hemodialysis. Report of the Diaphane collaborative study. Nephron 1982; 31:103.
  38. Iseki K, Yamazato M, Tozawa M, Takishita S. Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients. Kidney Int 2002; 61:1887.
  39. Di Micco L, Quinn RR, Ronksley PE, et al. Urine creatinine excretion and clinical outcomes in CKD. Clin J Am Soc Nephrol 2013; 8:1877.