Outcomes Quality Initiative Clinical Practice Research Articles

The Impact of Various Cycling Regimens on Phosphorus Removal in Chronic Peritoneal Dialysis Patients

The National Kidney Foundation Dialysis Outcome Quality Initiative clinical practice guidelines have suggested that serum phosphate levels be maintained at < or =5.5 mg/dL in patients maintained on dialysis. Over 45% of anuric patients maintained on CAPD have serum phosphate levels >5.5 mg/dL. The present study was designed to address the question whether phosphate removal could be enhanced by increasing the dialysate volume during cycler peritoneal dialysis therapy. Medically stable patients maintained on chronic peritoneal dialysis therapy, who were high or high-average transporters and had serum phosphate levels > or =5.5 mg/dL, were invited to participate in the study. The protocol involved measuring phosphate and creatinine clearances at weekly intervals on three different cycler prescriptions consisting of 7 and 12 full cycles or 24 cycles with 50% tidal PD (TPD) over 9 hours. Ten patients agreed to participate. Those patients (n=7) with a BMI > 22 had 2 liter (L) fill volumes and 14 L of total dialysate (7 cycles of 2 L) or 24 L total dialysate (12 cycles of 2 L or 50% TPD with 24 cycles).The patients (n=3) with a BMI < 20 had 1.2 L fill volumes and 8.4 L total dialysate (7 cycles) or 14.4 L total dialysate (12 cycles of 1.2 L or 50% TPD with 24 cycles). The mean age (+/- SD) of the study patients was 50.8 (+/- 9.3) years. There were 6 females, 6 Caucasians and 4 African-Americans. The mean weight of the patients was 71.5 (+/- 24.2) kg and mean height 1.65 (+ 7.6) meters. The mean BMI was 18.3 (+/- 1.27) in the < 20 BMI group and 30.3 (+/- 6.6) in the > 22 BMI group. The mean phosphate clearance (L/night/1.73m 2 ) increased from 3.96 (+/- 1.16) with 7 cycles to 4.71 (+ 1.81) with 12 cycles and 4.51 (+/- 1.61) with 50% TPD. Creatinine clearance (L/night/1.73m 2 ) was 4.74 (+/- 1.74) with 7 cycles, 6.06 (+/- 2.04) with 12 cycles and 5.61 (+/- 2.01) with TPD. The present study indicates that there is a significant, 19% (P < 0.005) rise in phosphate clearance by increasing dialysate volume 71% from 7 cycles to 14 cycles compared to a 27% increase in creatinine clearance. With tidal PD, phosphate clearance increased by 12% (p=NS) and creatinine clearance increased 18 % (p, 0.02). This increase in phosphate clearance translates into <50 mg net phosphate removal in 9 hours, assuming a serum phosphate of 6 mg/%. Thus, increasing dialysis cycles and volume results in only a minimal increase in net phosphate removal.

Review of the Effects of Omega-3 Supplementation in Dialysis Patients

Chronic dialysis patients experience a host of conditions that limit quality and length of life, and recent therapeutic strategies have had only modest success in ameliorating many of these problems. By mediating cell membrane function and structure and the synthesis of lipid mediators such as eicosanoids, omega-3 fatty acids may offer dialysis patients a host of therapeutic benefits. Omega-3 fatty acids are derived primarily from dietary sources, and cold-water fish is the main source of eicosapentanoic and docosahexanoic acids, the two major bioactive omega-3 fatty acids. Studies of omega-3 supplementation in dialysis patients describe salutary effects on triglyceride levels, dialysis access patency, and perhaps uremic pruritus and oxidative stress. In contrast, the putative hematologic, antihypertensive, anti-inflammatory, and antiarrhythmic effects are not as well documented. Adverse effects generally have been limited to gastrointestinal complaints. Unfortunately, the preponderance of published studies are characterized by suboptimal study design, small sample sizes, supraphysiologic omega-3 doses that may be difficult to consume for extended periods, little long-term follow-up, and a lack of confirmation of compliance. Not surprising, the 2005 National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients recommend further research in this field. In summary, although preliminary data suggest that omega-3 fatty acids may have clinical benefits, formal recommendations encouraging omega-3 supplementation of dialysis patients are premature until long-term and adverse effects are better defined.

Phosphate binder therapy for attainment of K/DOQI™ bone metabolism guidelines

Phosphate binder therapy for attainment of K/DOQI™ bone metabolism guidelines

Protein supplementation in patients using peritoneal dialysis

Protein-energy malnutrition is highly prevalent in peritoneal dialysis (PD) patients and is a major contributing factor to morbidity and mortality. 1 Mittman N. Avram M. Oo K. et al. Serum prealbumin predicts survival in hemodialysis and peritoneal dialysis 10 years of prospective observation. Am J Kidney Dis. 2001; 36: 1358-1364 Abstract Full Text Full Text PDF Scopus (70) Google Scholar Low serum albumin (SA) levels in PD patients are associated with increased morbidity and mortality. 2 Garibotto G. Pastorino N. Dertenois L. Protein and amino acid metabolism in renal disease and renal failure Effects of PD on protein turnover. in: Kopple J. Massry S. Nutritional Management of Renal Disease. ed 2. Lippincott, Philadelphia, PA2004: 15-18 Google Scholar , 3 Heimburger O. Stenvinkel P. Lindholm B. Nutritional management of chronic peritoneal dialysis. in: Kopple J. Massry S. Nutritional Management of Renal Disease. ed 2. Lippincott, Philadelphia, PA2004: 478-511 Google Scholar Risk factors for poor nutritional status and decreased SA may include protein loss, abdominal distention, nutrient metabolism alterations, metabolic acidosis, endocrine disorders, drug-nutrient interactions, blood loss, socioeconomic status, and psychologic status. 3 Heimburger O. Stenvinkel P. Lindholm B. Nutritional management of chronic peritoneal dialysis. in: Kopple J. Massry S. Nutritional Management of Renal Disease. ed 2. Lippincott, Philadelphia, PA2004: 478-511 Google Scholar , 4 McCann L. Malnutrition Detection and intervention. Perit Dial Int. 1999; 19: S527-S532 PubMed Google Scholar , 5 Heimburger O. Stenvinkel P. Lindholm B. New strategies for management of malnutrition in peritoneal dialysis patients. Perit Dial Int. 2000; 20: 271-275 PubMed Google Scholar Although SA may not reflect the exact degree of malnutrition, it is often used for classifying nutritional status and recommending dietary protein intake. 6 Schoenfeld P. Albumin is an unreliable marker of nutritional status. Semin Dial. 1992; 5: 218-223 Crossref Scopus (10) Google Scholar The Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guideline states, “A stable or rising SA concentration that is equal to or greater than the lower limit of the normal range (approximately 4.0 g/dL for the bromcresol green (BCG) method) is the outcome goal.” 7 National Kidney Foundation 2000 K/DOQI Guideline 26. Clinical practice guidelines for peritoneal dialysis; measurement of albumin concentration in PD patients. Available at: www.kidney.org/professionals/kdoqi/index.cfm. Accessed January 7, 2004. Google Scholar The average SA level for PD patients is 3.7 ± 0.4 (standard deviation [SD]) g/dL. 6 Schoenfeld P. Albumin is an unreliable marker of nutritional status. Semin Dial. 1992; 5: 218-223 Crossref Scopus (10) Google Scholar The average SA for the Timpanogos Peritoneal Dialysis (TPD) program using BCG methodology was 3.6 g/dL for the years 2000 and 2001.

The Dialysis Outcomes and Practice Patterns Study (DOPPS) and the Kidney Disease Outcomes Quality Initiative (K/DOQI): A cooperative initiative to improve outcomes for hemodialysis patients worldwide

The Dialysis Outcomes and Practice Patterns Study (DOPPS) and the Kidney Disease Outcomes Quality Initiative (K/DOQI): A cooperative initiative to improve outcomes for hemodialysis patients worldwide

Vascular access results from the Dialysis Outcomes and Practice Patterns Study (DOPPS): Performance against Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines

Vascular access results from the Dialysis Outcomes and Practice Patterns Study (DOPPS): Performance against Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines

Vascular access results from the Dialysis Outcomes and Practice Patterns Study (DOPPS): Performance against Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines

The Kidney Disease Outcomes Quality Initiative Guidelines for Vascular Access in hemodialysis patients recommend native arteriovenous (AV) fistulae over AV grafts or catheters for permanent vascular access. They recommend letting fistulae mature > or =1 month before cannulation. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides an unparalleled means to examine vascular access practice patterns and guidelines internationally, with particular attention to associations with mortality risk. Most patients in Europe and Japan dialyze through AV fistulae and very few use AV grafts; in the United States, more patients use grafts than fistulae. Patients who receive nephrologic care for over 30 days before starting dialysis have significantly higher chances of commencing via AV fistula. Medical directors of dialysis facilities in the United States commonly prefer grafts; in Europe and Japan, most prefer fistulae. In the United States, there is a relatively long average time between fistula creation and cannulation but significantly worse fistula survival than that seen in Europe. Tunneled catheters pose a higher mortality risk than permanent accesses and are associated with increased risk of failure of a subsequent fistula. The percentage of prevalent patients in the DOPPS countries using catheters has increased in recent years. DOPPS data suggest that performance in some countries falls short of practices achieved in other countries. AV fistula use is low in the United States but has been improving. The trend of increasing use of catheters in most countries is discouraging. The DOPPS will continue to monitor practice trends and explore whether greater application of guidelines will lead to fewer access complications and improved longevity for hemodialysis patients.

Nutrition interventions to address cardiovascular outcomes in chronic kidney disease

Nutrition interventions to address cardiovascular outcomes in chronic kidney disease

Introduction

Introduction

K/DOQI clinical practice guidelines for bone metabolism and disease in CKD

K/DOQI (Kidney Disease Outcome Quality Initiative) Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease were published last year. The Work Group screened enormous amount of articles and made up of sixteen guidelines for Bone metabolism and disease in Chronic Kidney Disease. This review provides brief an overview of guidelines with strong emphasis on vitamin D.

Consequences of hyperphosphatemia in patients with end-stage renal disease (ESRD)

Hyperphosphatemia is invariably present among patients with end-stage renal disease (ESRD) and is becoming an increasingly important clinical entity. Despite concerted efforts by patients, dietitians, and nephrologists to control serum phosphorus, a recent study by Block et al found that more than 60% of patients on hemodialysis in the United States have serum phosphorus levels above the recommended goal of 5.5 mg/dL. Historically, nephrologists have been concerned about the central role of elevated serum phosphorus in the pathogenesis of secondary hyperparathyroidism and extraosseous calcification. However, the consequences of untreated hyperphosphatemia have assumed more importance in the last few years, largely due to recent clinical studies that revealed a more sinister role of elevated serum phosphorus in increasing the mortality risk among patients with ESRD. Hemodialysis patients with serum phosphorus greater than 6.5 mg/dL were reported to have a 27% higher mortality risk than patients with serum phosphorus between 2.4 and 6.5 mg/dL. The pathophysiologic mechanisms by which persistent hyperphosphatemia enhances the mortality risk in dialysis patients are not yet completely understood. However, given that inadequate control of serum phosphorus contributes to elevated calcium-phosphorus product (Ca x P), untreated hyperphosphatemia may play a key role in cardiovascular calcification. In response to these findings, the National Kidney Foundation Kidney Disease Outcome Quality Initiative (K/DOQI) Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease have recently recommended more stringent levels for controlling serum phosphorus and Ca x P product in order to improve patients' quality of life and longevity.

Lipoprotein(a)- and low-density lipoprotein–derived cholesterol in nephrotic syndrome: Impact on lipid-lowering therapy?

Patients with nephrotic syndrome have the highest lipoprotein(a) [Lp(a)] concentrations known. Lp(a) is an low-density lipoprotein (LDL)-like particle consisting of 45% cholesterol. The usual methods to determine LDL cholesterol do not distinguish between cholesterol derived from LDL and Lp(a) and are thus the net result of cholesterol levels from both lipoproteins. High Lp(a) concentrations therefore significantly contribute to the measured or calculated LDL cholesterol levels. Since statins have no influence on Lp(a) levels, it can be expected that the LDL cholesterol-lowering effect of statins may be diminished in patients who have a pronounced elevation of Lp(a) levels accompanied by only moderate elevations of LDL cholesterol. We investigated 207 patients with nondiabetic nephrotic syndrome in whom Lp(a) concentrations were strikingly elevated when compared to 274 controls (60.4 +/- 85.4 mg/dL vs. 20.0 +/- 32.8 mg/dL, P < 0.0001). According to National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines for Managing Dyslipidemias, almost 95% of these patients are candidates for a therapeutic intervention to lower LDL cholesterol. LDL cholesterol levels corrected for Lp(a)-derived cholesterol, however, were 27 mg/dL lower than uncorrected concentrations (compared to only 9 mg/dL in controls). If Lp(a)-corrected levels instead of total LDL cholesterol levels were used, 25.7% of patients with low-molecular-weight (LMW) apolipoprotein(a) [apo(a)] isoforms were classified no longer to be in need of LDL cholesterol-lowering therapeutic intervention compared to only 2.3% of patients with high-molecular-weight (HMW) apo(a) phenotypes (P < 0.00001). This ("pseudo") pharmacogenetic effect results in incorrect determination of LDL cholesterol. Our observation has an impact on the indication for, and assessment of efficacy of intervention. This potential artifact should be investigated in ongoing large trials in renal patients as well as in nonrenal African American subjects who have on average markedly higher Lp(a) levels. In nonrenal Caucasian subjects with much lower Lp(a) concentrations, this issue will be less relevant.

Evidence-based data for the hemodialysis access surgeon.

The National Kidney Foundation Dialysis Outcomes Quality Initiative Clinical Practice Guidelines for Vascular Access (DOQI) have defined the access-related care for patients with end-stage renal disease (ESRD). However, the standard of care across the country has fallen short of the DOQI targets. One potential explanation for these shortcomings is the lack of compelling evidence in the literature to support the recommendations. This study was designed to compare the DOQI with the best available evidence in the literature for four clinical questions relevant to the hemodialysis access surgeon: the choice of access type (autogenous versus prosthetic), the type of prosthetic graft, management of the "failing" (nonthrombosed) access, and management of the thrombosed access. The electronic literature databases MEDLINE and Evidence-Based Medicine Reviews were searched and relevant randomized controlled trials or meta-analyses were identified for review. No randomized controlled trials comparing autogenous to prosthetic accesses were identified. However, a recent systematic review reported that the patency rates for upper extremity autogenous accesses were superior to their polytetrafluoroethylene (PTFE) counterparts. The identified randomized trials suggested that the patency rates for the different types of commercially available prosthetic grafts used for access appear comparable. They suggested that standard wall PTFE thickness and prosthetic anastomotic cuffs may be associated with better graft patency, while venous cuffs may be associated with worse patency. Furthermore, the trials suggested percutaneous angioplasty of "failing" prosthetic accesses with greater than 50% stenoses did not appear to improve patency and that routine use of intraluminal stents, as an adjunct to angioplasty, was not beneficial. They did suggest that patency after open surgical revision of "failing" prosthetic accesses was superior to that after percutaneous angioplasty. Lastly, the identified trials suggested that the patency rates after open surgical revision of thrombosed prosthetic accesses was better than after endovascular treatment. Despite the magnitude of hemodialysis-related access problems, the quality of the evidence supporting the clinical decisions relevant to the access surgeon is limited and further clinical trials are justified.

Developing clinical performance measures based on the Dialysis Outcomes Quality Initiative Clinical Practice Guidelines: process, outcomes, and implications1,2

Background:The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Clinical Practice Guidelines established a widely accepted set of recommendations for high-quality dialysis care. To enhance the End-Stage Renal Disease Core Indicators Project, an ongoing effort to assess and improve dialysis care in the United States, the Centers for Medicare and Medicaid Services (CMS) commissioned a project to develop clinical performance measures (CPMs) based on the NKF-DOQI guidelines. Methods:The CMS contracted with Qualis Health, a private nonprofit organization serving as a Medicare Quality Improvement Organization, to facilitate a 9-month project to develop dialysis CPMs with the participation of a broad range of stakeholders from the renal community. Work groups were established to develop CPMs addressing 4 areas: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access management, and anemia management. The NKF-DOQI guidelines were prioritized based on the strength of the evidence supporting the guidelines, the feasibility of developing performance measures, and the significance of the areas addressed to the quality of care delivered to dialysis patients. Expert panels developed data specifications, sampling approaches, data-collection tools, and analytic strategies. Results:Sixteen CPMs were developed based on 22 of 114 NKF-DOQI guidelines. After establishing reliability through field-testing of data-collection instruments, the CPMs were applied to a sample of 8,838 randomly selected hemodialysis patients and 1,650 randomly selected adult peritoneal dialysis patients in summer 1999. Conclusion:The development of CPMs based on the NKF-DOQI Clinical Practice Guidelines for dialysis care was accomplished in a timely and effective manner by engaging a broad range of stakeholders and technical experts. The CPMs are important tools to assess and improve the quality of dialysis care in the United States. Few comparable efforts exist in other fields of medicine.

Tips for cholesterol control in patients on hemodialysis

KIDNEY DISEASE is associated with a number of risk factors for cardiovascular disease (CVD) including a high incidence of diabetes, hypertension, and dyslipidemias. CVD accounts for almost half of all deaths among patients with end-stage renal disease (ESRD).1The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney DiseasesUSRDS US Renal Data System Annual Data Report. 1999Google Scholar Findings from a recent study indicate that dyslipidemias in hemodialysis (HD) patients—including increased serum low-density lipoprotein (LDL) cholesterol and decreased high-density lipoprotein (HDL) cholesterol—negatively impact cardiovascular profiles and influence both the frequency and length of hospitalizations.2Baugh M.E. Stoltz M.L. VanBeber A.D. et al.Are lipid values and BMI related to hospitalizations in the hemodialysis population?.J Ren Nutr. 2001; 11: 37-45Abstract Full Text PDF PubMed Google Scholar Paradoxically, although higher body mass index (BMI) is a risk factor for CVD in the general population,3Krauss R.M. Eckel R.H. Howard B. et al.AHA Dietary Guidelines: Revision 2000: A statement for healthcare professionals from the Nutrition Committee of the American Heart Association.Circulation. 2000; 102: 2284-2299Crossref PubMed Scopus (1393) Google Scholar maintaining BMI at the high end of the normal range (20–27.5 kg/m2) may reduce morbidity and mortality in HD patients.4Fleischmann E. Teal N. Dudley J. et al.Influence of excess weight on mortality and hospital stay in 1346 hemodialysis patients.Kidney Int. 1999; 55: 1560-1567Crossref PubMed Scopus (370) Google Scholar Furthermore, HD patients are encouraged to increase protein intake from animal sources (which are relatively high in fat, saturated fat, and cholesterol) to avoid the hypoalbuminemia that is also predictive of increased mortality.5National Kidney FoundationKidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Renal Failure.Am J Kidney Dis. 2000; 35: S40-S41Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Clearly, dietary management of these patients should focus on optimizing nutritional status while reducing risk factors for CVD. This teaching tool for HD patients has been adapted from an American Heart Association publication for the general population.6American Heart AssociationFighting Heart Disease and Stroke. 1998Google Scholar The handouts comprising this patient education tool address the selection of protein-rich foods while limiting saturated fat and cholesterol intake. In addition, providing information on “Foods to Eat” as well as “Foods to Avoid” encourages appropriate caloric intake for maintenance of acceptable BMI. These handouts can be used to teach HD patients with a history of high cholesterol and/or triglyceride levels about healthy food choices from each of the food groups. The information may be presented in its entirety or broken down to address the separate food groups over several counseling sessions.

The nutritional status of chronic renal failure patients following the initiation of hemodialysis treatment

The nutritional status of chronic renal failure patients following the initiation of hemodialysis treatment

Serum albumin measurement in dialysis patients: Should it be a measure of clinical performance*

Despite many years of work by renal nutritionists, protein-energy malnutrition remains very common among patients with advanced chronic kidney disease and those treated with dialysis.1 Adults with chronic kidney disease and protein-energy malnutrition have high mortality, and hypoalbuminemia at the initiation of chronic dialysis is highly predictive of future mortality.2-4 The Kidney/Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines for Nutrition of Chronic Renal Failure make recommendations for dialysis patient dietary protein intake.

Where Are All the AV Fistulas?

Increasing the prevalence of arteriovenous (AV) fistulas is crucial to decreasing the incidence and costs of dialysis access failure. Despite almost uniform agreement in the dialysis community of the need to increase AV fistulas, U.S. fistula prevalence has only increased modestly since the publication of the Dialysis Outcomes Quality Initiative (DOQI) clinical practice guidelines in 1997. Fistula rates of 28% in incident patients and 27% in prevalent patients [Health Care Finance Administration (HCFA) clinical performance measures project data for 1999] do not approach the fistula rates achieved by various focused U.S. programs, nor those routinely observed in Europe. Systemic barriers that limit the availability and funding of both pre-end-stage renal disease (ESRD) care and preoperative imaging, coupled with financial disincentives, lack of accountability, and educational deficiencies, impede progress toward increased fistula placement. Improvements in AV fistula prevalence require a realistic appraisal and correction of the system problems hindering achievement of this goal. The DOQI and Kidney Disease Outcomes and quality Initiative (K/DOQI) were excellent first steps; however, implementation will require modification of other structures that impact on patient care delivery.

The National Kidney Foundation K/DOQI clinical practice guidelines for dietary protein intake for chronic dialysis patients

This paper discusses two of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) clinical practice guidelines for nutrition in chronic renal failure. These are the guidelines that recommend a dietary protein intake of 1.2 g protein/kg body weight/day for clinically stable maintenance hemodialysis (MHD) patients (Guideline 15) and 1.2 to 1.3 g protein/kg/day for clinically stable chronic peritoneal dialysis (CPD) patients (Guideline 16). These recommended protein intakes are greater than the usually ingested protein intakes of MHD and CPD patients and are also greater than the recommended protein intakes for healthy, nonpregnant, nonlactating adults. The possible mechanisms that engender these increased protein needs include (1) the substantial quantity of amino acids, peptides, and proteins removed by the dialysis procedure and (2) the protein catabolic or antianabolic state caused by the uremic milieu, the inflammatory state, the oxidative and carbonyl stress, and the bioincompatible dialysis materials to which MHD and CPD patients are exposed. There are a number of nitrogen balance studies that have been performed to identify the dietary protein needs of MHD and CPD patents. The results of this research as well as some of the methodological limitations of these studies are reviewed. The concepts of the average dietary protein intake required to maintain protein balance in MHD or CPD patients and the safe protein intake that will maintain protein balance in virtually all MHD and CPD patients are discussed. © 2001 by the National Kidney Foundation, Inc.

National Kidney Foundation K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Renal Failure was recently published in the American Journal of Kidney Diseases . This publication provides 27 clinical practice guidelines for adults and 10 clinical practice guidelines for children. The adult guidelines focus primarily on patients undergoing maintenance dialysis therapy, although there are several clinical practice guidelines on nutritional issues for patients with advanced chronic renal failure (CRF) not undergoing dialysis therapy. The pediatric guidelines focus entirely on children undergoing maintenance dialysis treatment. The present article discusses a number of the more prominent clinical practice guidelines for the adults. Among these is the recommendation that the protein-energy nutritional status in these patients should be assessed by a panel of measures rather than by any single measure. Also, non-dialyzed patients with advanced CRF (ie, glomerular filtration rate <25 mL/min) and those undergoing maintenance hemodialysis or chronic peritoneal dialysis should be prescribed a dietary energy intake of 35 kcal/kg/day for patients who are <60 years of age and 30 kcal/kg for patients ≥60 years of age. Maintenance hemodialysis patients should be prescribed 1.2 g protein/kg/d; chronic peritoneal dialysis patients should be prescribed 1.2 to 1.3 g protein/kg/d. For non-dialyzed patients with CRF (glomerular filtration rate <25 mL/min), 0.60 g protein/kg/d should be prescribed. For patients who will not accept such a diet or are unable to maintain an adequate energy intake on that diet, a protein intake of up to 0.75 g protein/kg/d may be prescribed. At least 50% of the protein intake for all of these patients should be of high biologic value. A guideline concerning indications for inaugurating maintenance dialysis treatment or renal transplantation on the basis of deteriorating nutritional status is also given.