Objectives of Review: Protein-energy wasting (PEW) is a state of disordered catabolism resulting from metabolic and nutritional derangements in chronic disease states. Patients with chronic kidney disease (CKD), and end-stage renal disease (ESRD) in particular, have muscle wasting, sarcopenia, and cachexia that contribute to frailty and morbidity. Moreover, reverse epidemiology findings have strongly linked PEW with mortality in CKD and ESRD. Updated Findings: The malnutrition-inflammation score (KALANTAR Score) provides a useful tool to predict nutritional risk. A stronger focus on renal nutrition in renal patients is needed to attenuate cachexia and muscle loss. Malnutrition is a far greater threat in patients with renal disease than obesity, which means dietary counseling needs to be tailored to reflect this observation. The need to achieve optimal caloric intake is compounded by the need to limit excess protein intake in CKD, resulting in the need for energy supplementation to avoid PEW. Preventing PEW is the most pressing clinical concern in CKD/ESRD. Other nutritional issues to reckon in renal disease include the need to normalize serum bicarbonate to manage acidosis, uric acid control, and phosphorous control in CKD and ESRD. Exercise maybe beneficial, but further work is needed to prove a conclusive benefit via a randomized trial. Summary: PEW prevention is an integral part of renal nutrition and is of paramount importance given the obesity paradox. Integrative approaches by physicians and dieticians are needed to take a holistic view of a patient’s diet beyond just control of particular laboratory parameters.

Keywords:
Protein-energy wasting, Cachexia, Sarcopenia, KALANTAR score, Chronic kidney disease, End-stage renal disease
1.
Foque D, Kalantar-Zadeh K, Kopple J, Cano N, Chauvea P, Cuppari L, et al. A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease.
Kidney Int
. 2008 Feb;73(4):391–8.
2.
Obi Y, Qader H, Kovesdy CP, Kalantar-Zadeh K. Latest consensus and update on protein-energy wasting in chronic kidney disease.
Curr Opin Clin Nutr Metab Care
. 2015 May;18(3):254–62.
3.
Carrero JJ, Thomas F, Nagy K, Arogundade F, Avesani CM, Chan M, et al. Global Prevalence of Protein-Energy Wasting in Kidney Disease: A Meta-analysis of Contemporary Observational Studies From the International Society of Renal Nutrition and Metabolism.
J Ren Nutr
. 2018 Nov;28(6):380–92.
4.
Carrero JJ, Stenvinkel P, Cuppari L, Ikizler TA, Kalantar-Zadeh K, Kaysen G, et al. Etiology of the protein-energy wasting syndrome in chronic kidney disease: a consensus statement from the International Society of Renal Nutrition and Metabolism (ISRNM).
J Ren Nutr
. 2013 Mar;23(2):77–90.
5.
Wang XH, Mitch WE. Mechanisms of muscle wasting in chronic kidney disease.
Nat Rev Nephrol
. 2014 Sep;10(9):504–16.
6.
Ikizler TA, Cano NJ, Franch H, Fouque D, Himmelfarb J, Kalantar-Zadeh K, et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism.
Kidney Int
. 2013 Dec;84(6):1096–107.
7.
Su CT, Yabes J, Pike F, Weiner DE, Beddhu S, Burrowes JD, et al. Changes in anthropometry and mortality in maintenance hemodialysis patients in the HEMO Study.
Am J Kidney Dis
. 2013 Dec;62(6):1141–50.
8.
den Hoedt CH, Bots ML, Grooteman MP, van der Weerd NC, Penne EL, Mazairac AH, et al.; CONTRAST Investigators. Clinical predictors of decline in nutritional parameters over time in ESRD.
Clin J Am Soc Nephrol
. 2014 Feb;9(2):318–25.
9.
Kim Y, Molnar MZ, Rattanasompattikul M, Hatamizadeh P, Benner D, Kopple JD, et al. Relative contributions of inflammation and inadequate protein intake to hypoalbuminemia in patients on maintenance hemodialysis.
Int Urol Nephrol
. 2013 Feb;45(1):215–27.
10.
Amparo FC, Cordeiro AC, Carrero JJ, Cuppari L, Lindholm B, Amodeo C, et al. Malnutrition-inflammation score is associated with handgrip strength in nondialysis-dependent chronic kidney disease patients.
J Ren Nutr
. 2013 Jul;23(4):283–7.
11.
Rattanasompattikul M, Molnar MZ, Zaritsky JJ, Hatamizadeh P, Jing J, Norris KC, et al. Association of malnutrition-inflammation complex and responsiveness to erythropoiesis-stimulating agents in long-term hemodialysis patients.
Nephrol Dial Transplant
. 2013 Jul;28(7):1936–45.
12.
Riella MC. Nutritional evaluation of patients receiving dialysis for the management of protein-energy wasting: what is old and what is new?
J Ren Nutr
. 2013 May;23(3):195–8.
13.
Ujszaszi A, Czira ME, Fornadi K, Novak M, Mucsi I, Molnar MZ. Quality of life and protein-energy wasting in kidney transplant recipients.
Int Urol Nephrol
. 2012 Aug;44(4):1257–68.
14.
Czira ME, Lindner AV, Szeifert L, Molnar MZ, Fornadi K, Kelemen A, et al. Association between the Malnutrition-Inflammation Score and depressive symptoms in kidney transplanted patients.
Gen Hosp Psychiatry
. 2011 Mar-Apr;33(2):157–65.
15.
Fontes D, Generoso SV, Toulson Davisson Correia MI. Subjective global assessment: a reliable nutritional assessment tool to predict outcomes in critically ill patients.
Clin Nutr
. 2014 Apr;33(2):291–5.
16.
Rambod M, Bross R, Zitterkoph J, Benner D, Pithia J, Colman S, et.al. Association of Malnutrition-Inflammation Score with Quality of Life and Mortality in Hemodialysis Patients: a 5-Year Prospective Cohort Study.
Am J Kidney Dis
. 2009 Feb;53(2):298–309.
17.
Kang SH, Cho KH, Park JW, Yoon KW, Do JY. Geriatric Nutritional Risk Index as a prognostic factor in peritoneal dialysis patients.
Perit Dial Int
. 2013 Jul-Aug;33(4):405–10.
18.
Jung YS, You G, Shin HS, Rim H. Relationship between Geriatric Nutritional Risk Index and total lymphocyte count and mortality of hemodialysis patients.
Hemodial Int
. 2014 Jan;18(1):104–12.
19.
Tsai MT, Hu FH, Lien TJ, Chen PJ, Huang TP, Tarng DC. Interaction between geriatric nutritional risk index and decoy receptor 3 predicts mortality in chronic hemodialysis patients.
Am J Nephrol
. 2014;40(3):191–9.
20.
Beberashvili I, Azar A, Sinuani I, Kadoshi H, Shapiro G, Feldman L, et al. Comparison analysis of nutritional scores for serial monitoring of nutritional status in hemodialysis patients.
Clin J Am Soc Nephrol
. 2013 Mar;8(3):443–51.
21.
Cabezas-Rodriguez I, Carrero JJ, Zoccali C, Qureshi AR, Ketteler M, Floege J, et al. Influence of body mass index on the association of weight changes with mortality in hemodialysis patients.
Clin J Am Soc Nephrol
. 2013 Oct;8(10):1725–33.
22.
Moradi H, Streja E, Kashyap ML, Vaziri ND, Fonarow GC, Kalantar-Zadeh K. Elevated high-density lipoprotein cholesterol and cardiovascular mortality in maintenance hemodialysis patients.
Nephrol Dial Transplant
. 2014 Aug;29(8):1554–62.
23.
Park J, Ahmadi SF, Streja E, Molnar MZ, Flegal KM, Gillen D, et al. Obesity paradox in end-stage kidney disease patients.
Prog Cardiovasc Dis
. 2014 Jan-Feb;56(4):415–25.
24.
Molnar MZ, Streja E, Kovesdy CP, Bunnapradist S, Sampaio MS, Jing J, et al. Associations of body mass index and weight loss with mortality in transplant-waitlisted maintenance hemodialysis patients.
Am J Transplant
. 2011 Apr;11(4):725–36.
25.
Hruska KA, Mathew S, Lund R, Qui P, Pratt R. Hyperphosphatemia of Chronic Kidney Disease.
Kidney Int
. 2008;74(2):148–57.
26.
Vashistha T, Mehrotra R, Park J, Streja E, Dukkipati R, Nissenson AR, et al. Effect of age and dialysis vintage on obesity paradox in long-term hemodialysis patients.
Am J Kidney Dis
. 2014 Apr;63(4):612–22.
27.
Hoogeveen EK, Halbesma N, Rothman KJ, Stijnen T, van Dijk S, Dekker FW, et al.; Netherlands Cooperative Study on the Adequacy of Dialysis-2 (NECOSAD) Study Group. Obesity and mortality risk among younger dialysis patients.
Clin J Am Soc Nephrol
. 2012 Feb;7(2):280–8.
28.
Lu JL, Kalantar-Zadeh K, Ma JZ, Quarles LD, Kovesdy CP. Association of body mass index with outcomes in patients with CKD.
J Am Soc Nephrol
. 2014 Sep;25(9):2088–96.
29.
Obermayr RP, Temml C, Gutjahr G, Kainz A, Klauser-Braun R, Függer R, et al. Body mass index modifies the risk of cardiovascular death in proteinuric chronic kidney disease.
Nephrol Dial Transplant
. 2009 Aug;24(8):2421–8.
30.
Walker SR, Gill K, Macdonald K, Komenda P, Rigatto C, Sood MM, et al. Association of frailty and physical function in patients with non-dialysis CKD: a systematic review.
BMC Nephrol
. 2013 Oct;14(1):228.
31.
Kim JC, Kalantar-Zadeh K, Kopple JD. Frailty and protein-energy wasting in elderly patients with end stage kidney disease.
J Am Soc Nephrol
. 2013 Feb;24(3):337–51.
32.
McAdams-DeMarco MA, Law A, Salter ML, Boyarsky B, Gimenez L, Jaar BG, et al. Frailty as a novel predictor of mortality and hospitalization in individuals of all ages undergoing hemodialysis.
J Am Geriatr Soc
. 2013 Jun;61(6):896–901.
33.
Bao Y, Dalrymple L, Chertow GM, Kaysen GA, Johansen KL. Frailty, dialysis initiation, and mortality in end-stage renal disease.
Arch Intern Med
. 2012 Jul;172(14):1071–7.
34.
Matsuzawa R, Matsunaga A, Wang G, Yamamoto S, Kutsuna T, Ishii A, et al. Relationship between lower extremity muscle strength and all-cause mortality in Japanese patients undergoing dialysis.
Phys Ther
. 2014 Jul;94(7):947–56.
35.
Johansen KL, Dalrymple LS, Delgado C, Kaysen GA, Kornak J, Grimes B, et al. Association between body composition and frailty among prevalent hemodialysis patients: a US Renal Data System special study.
J Am Soc Nephrol
. 2014 Feb;25(2):381–9.
36.
Reese PP, Cappola AR, Shults J, Townsend RR, Gadegbeku CA, Anderson C, et al.; CRIC Study Investigators. Physical performance and frailty in chronic kidney disease.
Am J Nephrol
. 2013;38(4):307–15.
37.
John SG, Sigrist MK, Taal MW, McIntyre CW. Natural history of skeletal muscle mass changes in chronic kidney disease stage 4 and 5 patients: an observational study.
PLoS One
. 2013 May;8(5):e65372.
38.
Di Micco L, Quinn RR, Ronksley PE, Bellizzi V, Lewin AM, Cianciaruso B, et al.; Alberta Kidney Disease Network (AKDN). Urine creatinine excretion and clinical outcomes in CKD.
Clin J Am Soc Nephrol
. 2013 Nov;8(11):1877–83.
39.
Patel SS, Molnar MZ, Tayek JA, Ix JH, Noori N, Benner D, et al. Serum creatinine as a marker of muscle mass in chronic kidney disease: results of a cross-sectional study and review of literature.
J Cachexia Sarcopenia Muscle
. 2013 Mar;4(1):19–29.
40.
Canaud B, Granger Vallée A, Molinari N, Chenine L, Leray-Moragues H, Rodriguez A, et al. Creatinine index as a surrogate of lean body mass derived from urea Kt/V, pre-dialysis serum levels and anthropometric characteristics of haemodialysis patients.
PLoS One
. 2014 Mar;9(3):e93286.
41.
Park J, Jin DC, Molnar MZ, Dukkipati R, Kim YL, Jing J, et al. Mortality predictability of body size and muscle mass surrogates in Asian vs white and African American hemodialysis patients.
Mayo Clin Proc
. 2013 May;88(5):479–86.
42.
Kalantar-Zadeh K, Streja E, Kovesdy CP, Oreopoulos A, Noori N, Jing J, et al. The obesity paradox and mortality associated with surrogates of body size and muscle mass in patients receiving hemodialysis.
Mayo Clin Proc
. 2010 Nov;85(11):991–1001.
43.
Kalantar-Zadeh K, Streja E, Molnar MZ, Lukowsky LR, Krishnan M, Kovesdy CP, et al. Mortality prediction by surrogates of body composition: an examination of the obesity paradox in hemodialysis patients using composite ranking score analysis.
Am J Epidemiol
. 2012 Apr;175(8):793–803.
44.
Onofriescu M, Hogas S, Voroneanu L, Apetrii M, Nistor I, Kanbay M, et al. Bioimpedance-guided fluid management in maintenance hemodialysis: a pilot randomized controlled trial.
Am J Kidney Dis
. 2014 Jul;64(1):111–8.
45.
Wu HL, Sung JM, Kao MD, Wang MC, Tseng CC, Chen ST. Nonprotein calorie supplement improves adherence to low-protein diet and exerts beneficial responses on renal function in chronic kidney disease.
J Ren Nutr
. 2013l Jul;23(4):271–6.
46.
Kovesdy CP, Kopple JD, Kalantar-Zadeh K. Management of protein-energy wasting in non-dialysis-dependent chronic kidney disease: reconciling low protein intake with nutritional therapy.
Am J Clin Nutr
. 2013 Jun;97(6):1163–77.
47.
Levine ME, Suarez JA, Brandhorst S, Balasubramanian P, Cheng CW, Madia F, et al. Low protein intake is associated with a major reduction in IGF-1, cancer, and overall mortality in the 65 and younger but not older population.
Cell Metab
. 2014 Mar;19(3):407–17.
48.
Lukowsky LR, Kheifets L, Arah OA, Nissenson AR, Kalantar-Zadeh K. Nutritional predictors of early mortality in incident hemodialysis patients.
Int Urol Nephrol
. 2014 Jan;46(1):129–40.
49.
Ravel VA, Molnar MZ, Streja E, Kim JC, Victoroff A, Jing J, et al. Low protein nitrogen appearance as a surrogate of low dietary protein intake is associated with higher all-cause mortality in maintenance hemodialysis patients.
J Nutr
. 2013 Jul;143(7):1084–92.
50.
Rattanasompattikul M, Molnar MZ, Lee ML, Dukkipati R, Bross R, Jing J, et al. Anti-Inflammatory and Anti-Oxidative Nutrition in Hypoalbuminemic Dialysis Patients (AIONID) study: results of the pilot-feasibility, double-blind, randomized, placebo-controlled trial.
J Cachexia Sarcopenia Muscle
. 2013 Dec;4(4):247–57.
51.
Cheu C, Pearson J, Dahlerus C, Lantz B, Chowdhury T, Sauer PF, et al. Association between oral nutritional supplementation and clinical outcomes among patients with ESRD.
Clin J Am Soc Nephrol
. 2013l Jan;8(1):100–7.
52.
Lacson E Jr, Wang W, Zebrowski B, Wingard R, Hakim RM. Outcomes associated with intradialytic oral nutritional supplements in patients undergoing maintenance hemodialysis: a quality improvement report.
Am J Kidney Dis
. 2012l Oct;60(4):591–600.
53.
Palmer SC, Hayen A, Macaskill P, Pellegrini F, Craig JC, Elder GJ, et al. Serum levels of phosphorus, parathyroid hormone, and calcium and risks of death and cardiovascular disease in individuals with chronic kidney disease: a systematic review and meta-analysis.
JAMA
. 2011 Mar;305(11):1119–27.
54.
Jamal SA, Vandermeer B, Raggi P, Mendelssohn DC, Chatterley T, Dorgan M, et al. Effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease: an updated systematic review and meta-analysis.
Lancet
. 2013 Oct;382(9900):1268–77.
55.
Streja E, Lau WL, Goldstein L, Sim JJ, Molnar MZ, Nissenson AR, et al. Hyperphosphatemia is a combined function of high serum PTH and high dietary protein intake in dialysis patients.
Kidney Int Suppl (2011)
. 2013 Dec;3(5):462–8.
56.
Lertdumrognluk P, Rhee CM, Park J, Lau WL, Moradi H, Jing J, et.al. Association of serum phosphorous concentration with mortality in elderly and non-elderly hemodialysis patients. J Ren Nutr. 2013 Nov;23(6):411–21.
57.
Yamada S, Tokumoto M, Tatsumoto N, Taniguchi M, Noguchi H, Nakano T, et al. Phosphate overload directly induces systemic inflammation and malnutrition as well as vascular calcification in uremia.
Am J Physiol Renal Physiol
. 2014 Jun;306(12):F1418–28.
58.
Shinaberger CS, Greenland S, Kopple JD, Van Wyck D, Mehrotra R, Kovesdy CP, et al. Is controlling phosphorus by decreasing dietary protein intake beneficial or harmful in persons with chronic kidney disease?
Am J Clin Nutr
. 2008 Dec;88(6):1511–8.
59.
Kalantar-Zadeh K, Uppot RN, Lewandrowski KB. Case records of the Massachusetts General Hospital. Case 23-2013. A 54-year-old woman with abdominal pain, vomiting, and confusion.
N Engl J Med
. 2013 Jul;369(4):374–82.
60.
Kalantar-Zadeh K, Mehrotra R, Fouque D, Kopple JD. Metabolic acidosis and malnutrition-inflammation complex syndrome in chronic renal failure.
Semin Dial
. 2004 Nov-Dec;17(6):455–65.
61.
Kalantar-Zadeh K, Fouque D. Nutritional Management of Chronic Kidney Disease.
N Engl J Med
. 2017 Nov;377(18):1765–76.
62.
Chen JL, Kalantar-Zadeh K. Is an increased serum bicarbonate concentration during hemodialysis associated with an increased risk of death?
Semin Dial
. 2014 May-Jun;27(3):259–62.
63.
Łoniewski I, Wesson DE. Bicarbonate therapy for prevention of chronic kidney disease progression.
Kidney Int
. 2014 Mar;85(3):529–35.
64.
Kovesdy CP. Metabolic acidosis and kidney disease: does bicarbonate therapy slow the progression of CKD?
Nephrol Dial Transplant
. 2012 Aug;27(8):3056–62.
65.
Dobre M, Yang W, Chen J, Drawz P, Hamm LL, Horwitz E, et al.; CRIC Investigators. Association of serum bicarbonate with risk of renal and cardiovascular outcomes in CKD: a report from the Chronic Renal Insufficiency Cohort (CRIC) study.
Am J Kidney Dis
. 2013 Oct;62(4):670–8.
66.
Kovesdy CP, Anderson JE, Kalantar-Zadeh K. Association of serum bicarbonate levels with mortality in patients with non-dialysis-dependent CKD.
Nephrol Dial Transplant
. 2009 Apr;24(4):1232–7.
67.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guidelines for the Evaluation and Management of Chronic Kidney Disease.
Kidney Int Suppl
. 2013;3:1–150.
68.
Vashistha T, Kalantar-Zadeh K, Molnar MZ, Torlén K, Mehrotra R. Dialysis modality and correction of uremic metabolic acidosis: relationship with all-cause and cause-specific mortality.
Clin J Am Soc Nephrol
. 2013 Feb;8(2):254–64.
69.
Tentori F, Karaboyas A, Robinson BM, Morgenstern H, Zhang J, Sen A, et al. Association of dialysate bicarbonate concentration with mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS).
Am J Kidney Dis
. 2013 Oct;62(4):738–46.
70.
Kim JC, Shapiro BB, Zhang M, Li Y, Porszasz J, Bross R, et al. Daily physical activity and physical function in adult maintenance hemodialysis patients.
J Cachexia Sarcopenia Muscle
. 2014 Sep;5(3):209–20.
71.
Cheema BS, Chan D, Fahey P, Atlantis E. Effect of progressive resistance training on measures of skeletal muscle hypertrophy, muscular strength and health-related quality of life in patients with chronic kidney disease: a systematic review and meta-analysis.
Sports Med
. 2014 Aug;44(8):1125–38.
72.
Kirkman DL, Mullins P, Junglee NA, Kumwenda M, Jibani MM, Macdonald JH. Anabolic exercise in haemodialysis patients: a randomised controlled pilot study.
J Cachexia Sarcopenia Muscle
. 2014 Sep;5(3):199–207.
73.
Watson EL, Kosmadakis GC, Smith AC, Viana JL, Brown JR, Molyneux K, et al. Combined walking exercise and alkali therapy in patients with CKD4-5 regulates intramuscular free amino acid pools and ubiquitin E3 ligase expression.
Eur J Appl Physiol
. 2013 Aug;113(8):2111–24.
74.
Cheng XS, Lentine KL, Koraishy FM, Myers J, Tan JC. Implications of Frailty for Peritransplant Outcomes in Kidney Transplant Recipients.
Curr Transplant Rep
. 2019 Mar;6(1):16–25.
75.
Kistler BM, Benner D, Burrowes JD, Campbell KL, Fouque D, Garibotto G, et al. Eating During Hemodialysis Treatment: A Consensus Statement From the International Society of Renal Nutrition and Metabolism.
J Ren Nutr
. 2018 Jan;28(1):4–12.
76.
Kalantar-Zadeh K, Cano NJ, Budde K, Chazot C, Kovesdy CP, Mak RH, et al. Diets and enteral supplements for improving outcomes in chronic kidney disease.
Nat Rev Nephrol
. 2011 May;7(7):369–84.
77.
Kalantar-Zadeh K, Kovesdy CP, Bross R, Benner D, Noori N, Murali SB, et al. Design and development of a dialysis food frequency questionnaire.
J Ren Nutr
. 2011 May;21(3):257–62.
78.
Abe M, Kalantar-Zadeh K. Haemodialysis-induced hypoglycaemia and glycaemic disarrays.
Nat Rev Nephrol
. 2015 May;11(5):302–13.
79.
Rambod M, Kovesdy CP, Bross R, Kopple JD, Kalantar-Zadeh K. Association of serum prealbumin and its changes over time with clinical outcomes and survival in patients receiving hemodialysis.
Am J Clin Nutr
. 2008 Dec;88(6):1485–94.
80.
Wang AY, Kalantar-Zadeh K, Fouque D, Wee PT, Kovesdy CP, Price SR, et al. Precision Medicine for Nutritional Management in End-Stage Kidney Disease and Transition to Dialysis.
Semin Nephrol
. 2018 Jul;38(4):383–96.
81.
Cupisti A, Kovesdy CP, D’Alessandro C, Kalantar-Zadeh K. Dietary Approach to Recurrent or Chronic Hyperkalaemia in Patients with Decreased Kidney Function.
Nutrients
. 2018 Feb;10(3):E261.
82.
Kalantar-Zadeh K, Tortorici AR, Chen JL, Kamgar M, Lau WL, Moradi H, et al. Dietary restrictions in dialysis patients: is there anything left to eat?
Semin Dial
. 2015 Mar-Apr;28(2):159–68.
83.
Kistler B, Benner D, Burgess M, Stasios M, Kalantar-Zadeh K, Wilund KR. To eat or not to eat-international experiences with eating during hemodialysis treatment.
J Ren Nutr
. 2014 Nov;24(6):349–52.
84.
Noori N, Kovesdy CP, Dukkipati R, Kim Y, Duong U, Bross R, et.al. Survival predictability of lean and fat mass in men and women undergoing maintenance hemodialysis.
Am J Clin Nutr
. 2010 Nov,92(5):1060–70.
85.
Liu X, Zhai T, Ma R, Luo C, Wang H, Liu L. Effects of uric acid-lowering therapy on the progression of chronic kidney disease: a systematic review and meta-analysis.
Ren Fail
. 2018 Nov;40(1):289–97.
© 2019 S. Karger AG, Basel
2019
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.