Background: Malnutrition is a frequently observed disorder in patients with chronic kidney disease (CKD) receiving hemodialysis (HD). While variously defined, malnutrition is a frequently observed condition among patients on HD. Prevalence estimates of malnutrition among Israeli HD patients have not been reported. Objectives: To survey nutrition intake in Israeli HD patients; estimate malnutrition risk prevalence; identify risk factors, and characterize malnutrition risk in HD patients. Methods: A representative sample of 378 Israeli HD patients treated in hospital HD centers throughout the country were surveyed. Using the 24-h recall method, dietary intake was estimated and the chronologically corresponding biochemistry, anthropometric, and hemodynamic measures were recorded. Four categories of malnutrition risk were defined: “minimal”: body mass index (BMI) > 23 kg/m2 and serum albumin > 3.8 g/dL; “mild”: BMI < 23 kg/m2 and albumin > 3.8 g/dL; “moderate”: BMI > 23 kg/m2 and albumin < 3.8 g/dL; “severe”: BMI < 23 k/m2 and serum albumin < 3.8 g/dL. Results: Elevated malnutrition risk was identified in 175 (46.3%) study participants, who were more likely to require feeding assistance, have major comorbidities, reduced hemoglobin, and elevated C-reactive protein. Oral nutrition supplementation was prescribed to only 14.3% of patients with elevated malnutrition risk. Intradialytic parenteral nutrition was recorded for 6 patients, all of whom had moderate or severe malnutrition risk. Less than one-third of patients met the guidelines for dietary intake of energy or protein, and this did not differ across malnutrition risk groups. Discussion: Elevated malnutrition risk is a frequent finding in HD patients treated in hospital settings in Israel. Dietary intake does not meet guidelines but does not differ across malnutrition risk categories. Nutrition supplements are underused in HD patients with high malnutrition risk. There is a need to expand the survey to community HD centers.

Carrero JJ, Stenvinkel P, Cuppari L, Ikizler TA, Kalantar-Zadeh K, Kaysen G, Mitch WE, Price SR, Wanner C, Wang AY, ter Wee P, Franch HA: 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; 23: 77–90.
Carrero JJ, Avesani CM: Pros and cons of body mass index as a nutritional and risk assessment tool in dialysis patients. Semin Dial 2015; 28: 48–58.
Leal VO, Moraes C, Stockler-Pinto MB, Lobo JC, Farage NE, Velarde LG, Fouque D, Mafra D: Is a body mass index of 23 kg/m2 a reliable marker of protein-energy wasting in hemodialysis patients? Nutrition 2012; 28: 973–977.
Cohen E, Fraser A, Goldberg E, Milo G, Garty M, Krause I: Association between the body mass index and chronic kidney disease in men and women. a population-based study from Israel. Nephrol Dial Transplant 2013; 28(suppl 4):iv130–iv135.
Neyra R, Chen KY, Sun M, Shyr Y. Hakim RM, Ikizler TA: Increased resting energy expenditure in patients with end-stage renal disease. JPEN J Parenter Enteral Nutr 2003; 27: 36–42.
Jofré R, Rodriguez-Benitez P, López-Gómez JM, Pérez-Garcia R: Inflammatory syndrome in patients on hemodialysis. J Am Soc Nephrol 2006; 17(suppl 3):S274–S280.
Wang H, Ye J: Regulation of energy balance by inflammation: common theme in physiology and pathology. Rev Endocr Metab Disord 2015; 16: 47–54.
Kaysen GA, Greene T, Daugirdas JT, Kimmel PL, Schulman GW, Toto RD, Levin NW, Yan G; HEMO Study Group. Longitudinal and cross-sectional effects of C-reactive protein, equilibrated normalized protein catabolic rate, and serum bicarbonate on creatinine and albumin levels in dialysis patients. Am J Kidney Dis 2003; 42: 1200–1211.
Nakashima A, Ohkido I, Yokoyama K, Mafune A, Urashima M, Yokoo T: Associations between low serum testosterone and all-cause mortality and infection-related hospitalization in male hemodialysis patients: a prospective cohort study. Kidney Int Rep 2017; 2: 1160–1168.
Carrero JJ, Qureshi AR, Axelsson J, Yilmaz MI, Rehnmark S, Witt MR, et al: Clinical and biochemical implications of low thyroid hormone levels (total and free forms) in euthyroid patients with chronic kidney disease. J Intern Med 2007; 262: 690–701.
Price SR, Gooch JL, Donaldson SK, Roberts-Wilson TK: Muscle atrophy in chronic kidney disease results from abnormalities in insulin signaling. J Ren Nutr 2010; 20(5 suppl):S24–S28.
de Brito-Ashurst I, Varagunam M, Raftery MJ, Yaqoob MM: Bicarbonate supplementation slows progression of CKD and improves nutritional status. J Am Soc Nephrol 2009; 20: 2075–2084.
Pupim LB, Heimburger O, Qureshi AR, Ikizler TA, Stenvinkel P: Accelerated lean body mass loss in incident chronic dialysis patients with diabetes mellitus. Kidney Int 2005; 68: 2368–2374.
Pupim LB, Cuppari L, Ikizler TA: Nutrition and metabolism in kidney disease. Semin Nephrol 2006; 26: 134–57.
de Roij van Zuijdewijn CL, ter Wee PM, Chapdelaine I, Bots ML, Blankestijn PJ, van den Dorpel MA, Nubé MJ, Grooteman MP: A comparison of 8 nutrition-related tests to predict mortality in hemodialysis patients. J Ren Nutr 2015; 25: 412–419.
Kikuchi H, Kanda E, Mandai S, Akazawa M, Iimori S, Oi K, Naito S, Noda Y, Toda T, Tamura T, Sasaki S, Sohara E, Okado T, Rai T, Uchida S: Combination of low body mass index and serum albumin level is associated with chronic kidney disease progression: the chronic kidney disease-research of outcomes in treatment and epidemiology (CKD-ROUTE) study. Clin Exp Nephrol 2017; 21: 55–62.
Vegine PM, Fernandes AC, Torres MR, Silva MI, Avesani CM: Assessment of methods to identify protein-energy wasting in patients on hemodialysis. J Bras Nefrol 2011; 33: 55–61.
Moshfegh AJ, Rhodes DG, Baer DJ, Murayi T, Clemens JC, Rumpler WV, Paul DR, Sebastian RS, Kuczynski KJ, Ingwersen LA, Staples RC, Cleveland LE: The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes. Am J Clin Nutr 2008; 88: 324–332.
Zhu Y, Hollis JH: Associations between eating frequency and energy intake, energy density, diet quality and body weight status in adults from the USA. Br J Nutr 2016; 115: 2138–2144.
Bonner M, Wright DJ: Practical Pharmaceutical Calculations. Oxford, Radcliffe Publishing, 2008.
Kaysen GA: Serum albumin concentration in dialysis patients: why does it remain resistant to therapy? Kidney Int Suppl 2003; 87:S92–S98.
Mills S, Brown H, Wrieden W, White M, Adams J: Frequency of eating home cooked meals and potential benefits for diet and health: cross-sectional analysis of a population-based cohort study. Int J Behavl Nutr Phys Act 2017; 14: 109.
Fouque D, Kalantar-Zadeh K, Kopple J, Cano N, Chauveau P, Cuppari L, Franch H, Guarnieri G, Ikizler TA, Kaysen G, Lindholm B, Massy Z, Mitch W, Pineda E, Stenvinkel P, Treviño-Becerra A, Wanner C: A proposed nomenclature and diagnostic criteria for protein-energy wasting in acute and chronic kidney disease. Kidney Int 2008; 73: 391–398.
National Kidney Foundation: KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. Am J Kidney Dis 2015; 66: 884–930.
Sabatino A, Regolisti G, Antonucci E, Cabassi A, Morabito S, Fiaccadori E: Intradialytic parenteral nutrition in end-stage renal disease: practical aspects, indications and limits. J Nephrol 2014; 27: 377–383.
Ikizler TA: Optimal nutrition in hemodialysis patients. Adv Chronic Kidney Dis 2013; 20: 181–189.
Antunes SA, Canziani ME, Campos AF, Vilela RQ: Hypoalbuminemia seems to be associated with a higher rate of hospitalization in hemodialysis patients. J Bras Nefrol 2016; 38: 70–75.
Wang J, Streja E, Soohoo M, Chen JL, Rhee CM, Kim T, Molnar MZ, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K: Concurrence of serum creatinine and albumin with lower risk for death in twice-weekly hemodialysis patients. J Ren Nutr 2017; 27: 26–36.
Lopes MB, Silva LF, Lopes GB, Penalva MA, Matos CM, Robinson BM, Lopes AA: Additional contribution of the malnutrition-inflammation score to predict mortality and patient-reported outcomes as compared with its components in a cohort of African descent hemodialysis patients. J Ren Nutr 2017; 27: 45–52.
Friedman AN, Fadem SZ: Reassessment of albumin as a nutritional marker in kidney disease. J Am Soc Nephrol 2010; 21: 223–230.
Hyun YY, Lee KB, Han SH, Kim YH, Kim YS, Lee SW, Oh YK, Chae DW, Ahn C: Nutritional status in adults with predialysis chronic kidney disease: KNOW-CKD study. J Korean Med Sci 2017; 32: 257–263.
Dai L, Golembiewska E, Lindholm B, Stenvinkel P: End-stage renal disease, inflammation and cardiovascular outcomes. Contrib Nephrol 2017; 191: 32–43.
Jagadeswaran D, Indhumathi E, Hemamalini AJ, Sivakumar V, Soundararajan P, Jayakumar M: Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients. Clin Nutr 2018;pii: S0261–5614(18)30001–3.
Boaz M, Chernin G, Schwartz I, Katzir Z, Schwartz D, Agbaria A, Gal-Oz A, Weinstein T: C-reactive protein and carotid and femoral intima media thickness: predicting inflammation. Clin Nephrol 2013; 80: 449–455.
Kalantar-Zadeh K, McAllister CJ, Lehn RS, Lee GH, Nissenson AR, Kopple JD: Effect of malnutrition-inflammation complex syndrome on EPO hyporesponsiveness in maintenance hemodialysis patients. Am J Kidney Dis 2003; 42: 761–773.
Rhee JJ, Ding VY, Rehkopf DH, Arce CM, Winkelmayer WC: Correlates of poor glycemic control among patients with diabetes initiating hemodialysis for end-stage renal disease. BMC Nephrol 2015; 16: 204.
Sridhar NR, Josyula S: Hypoalbuminemia in hemodialyzed end stage renal disease patients: risk factors and relationships – a 2 year single center study. BMC Nephrol 2013; 14: 242.
Schroijen MA, van de Luijtgaarden MW, Noordzij M, Ravani P, Jarraya F, Collart F, Prütz KG, Fogarty DG, Leivestad T, Prischl FC, Wanner C, Dekker FW, Jager KJ, Dekkers OM: Survival in dialysis patients is different between patients with diabetes as primary renal disease and patients with diabetes as a co-morbid condition. Diabetologia 2013; 56: 1949–1957.
Bataille S, Landrier JF, Astier J, Cado S, Sallette J, Giaime P, Sampol J, Sichez H, Ollier J, Gugliotta J, Serveaux M, Cohen J, Darmon P: Haemodialysis patients with diabetes eat less than those without: a plea for a permissive diet. Nephrology 2017; 22: 712–719.
Kaysen GA, Don BR: Factors that affect albumin concentration in dialysis patients and their relationship to vascular disease. Kidney Int Suppl 2003; 84:S94–S97.
Hou F, Jiang J, Chen J, Yu X, Zhou Q, Chen P, Mei C, Xiong F, Shi W, Zhou W, Liu X, Sun S, Xie D, Liu J, Zhang P, Yang X, Zhang Y, Zhang Y, Liang X, Zhang Z, Lin Q, Yu Y, Wu S, Xu X: China collaborative study on dialysis: a multi-centers cohort study on cardiovascular diseases in patients on maintenance dialysis. BMC Nephrol 2012; 3: 94.
Kaya T, Sipahi S, Cinemre H, Karacaer C, Varim C, Nalbant A, et al: Relationship between the target dose for hemodialysis adequacy and nutritional assessment. Ann Saudi Med 2016; 36: 121–127.
Miller JE, Kovesdy CP, Nissenson AR, Mehrotra R, Streja E, Van Wyck D, Greenland S, Kalantar-Zadeh K: Association of hemodialysis treatment time and dose with mortality and the role of race and sex. Am J Kidney Dis 2010; 55: 100–112.
Roach LA, Lambert K, Holt JL, Meyer BJ: Diet quality in patients withend-stage kidney disease undergoing dialysis. J Ren Care 2017; 43: 226–234.
Alvarenga LA, Andrade BD, Moreira MA, Nascimento RP, Macedo ID, Aguiar AS: Nutritional profile of hemodialysis patients concerning treatment time. J Bras Nefrol 2017; 39: 283–286.
Beddhu S, Wei G, Chen X, Boucher R, Kiani R, Raj D, Chonchol M, Greene T, Murtaugh MA: Associations of dietary protein and energy intakes with protein-energy wasting syndrome in hemodialysis patients. Kidney Int Rep 2017; 2: 821–830.
Benner D, Brunelli SM, Brosch B, Wheeler J, Nissenson AR: Effects of oral nutritional supplements on mortality, missed dialysis treatments, and nutritional markers in hemodialysis patients. J Ren Nutr 2017; pii: S1051–2276(17)30252–2.
Martin-Alemañy G, Valdez-Ortiz R, Olvera-Soto G, Gomez-Guerrero I, Aguire-Esquivel G, Cantu-Quintanilla G, Lopez-Alvarenga JC, Miranda-Alatriste P, Espinosa-Cuevas A: The effects of resistance exercise and oral nutritional supplementation during hemodialysis on indicators of nutritional status and quality of life. Nephrol Dial Transplant 2016; 31: 1712–1720.
Kistler BM, Benner D, Burrowes JD, Campbell KL, Fouque D, Garibotto G, Kopple JD, Kovesdy CP, Rhee CM, Steiber A, Stenvinkel P, Ter Wee P, Teta D, Wang AY, -Kalantar-Zadeh K: Eating during hemodialysis treatment: a consensus statement from the International Society of Renal Nutrition and Metabolism. J Ren Nutr 2018; 28: 4–12.
Israel Center for Disease Control. Renal Replacement Therapy in Israel, 1990–2015. Ministry of Health, 2018.
Thompson FE, Subar AF: Chapter 1. Dietary assessment methodology; in Coultson AM, Boushey CJ, Ferruzzi MG (eds) Nutrition in the Prevention and Treatment of Disease (ed 3). San Diego, Elsevier Press, 2013.
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