Simplified Adequate Energy Requirements for Patients on Maintaince Hemodialysis in Taiwan: A Cross- Sectional Observation Study

Research Article

Austin J Nutri Food Sci. 2016; 4(1): 1074.

Simplified Adequate Energy Requirements for Patients on Maintaince Hemodialysis in Taiwan: A Cross- Sectional Observation Study

Lu YJ¹, Chen TW², Chen TH³, Yang SH¹, Lin WC¹, Wu PY¹ and Yang SH¹*

¹School of Nutrition and Health Sciences, Taipei Medical University, Taiwan

²Nephrology, Taipei Medical University Hospital, Taiwan

³Nephrology, Taipei Wan Fang Hospital, Taiwan

*Corresponding author: Yang SH, School of Nutrition and Health Sciences, Taipei Medical University, No. 250, Wu-Xin Street, Taipei City, Taiwan

Received: September 28, 2015; Accepted: January 07, 2016; Published: January 11, 2016


Background: Taiwanese studies have typically shown that the average Dietary Energy Intake (DEI) of Hemodialysis (HD) patients was lower than that recommended by the National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines; however, these patients did not display a poor nutritional status. This study aimed to use the energy prediction equation to estimate simplified Appropriate Energy Requirements (AER) for Taiwanese HD patients.

Design: This was a cross-sectional study with 108 HD patients. The demographic, anthropometric, and laboratory measurement data of the patients were obtained from a chart review. The dietary data were obtained from 3-day dietary records at the baseline and follow-up periods of the current study.

Result: To maintain an ideal body weight and a healthy nutritional status, the AER for males is approximately 24.6 (kcal/IBW kg/day) and the AER for females is approximately 21.0 (kcal/IBW kg/day). Based on the DEI reached AER, a comparison of the nutritional parameters between the baseline and follow-up was non-significant. Male patients older than 60 years with adequate dietary energy showed higher serum albumin values and Geriatric Nutritional Risk Index (GNRI) scores in the follow-up compared with those at the baseline.

Conclusion: The AER of Taiwanese HD patients may be lower than the recommendation of the K/DOQI guideline. We recommend an AER of approximately 21 to 25 (kcal/kg/day) to maintain an ideal body weight and a healthy nutritional status.

Keywords: Hemodialysis; Energy requirement; Equation of energy requirements; Nutritional status; Energy intake


AER: Appropriate Energy Requirements; APR: Appropriate Protein Requirement; BUN: Blood Urea Nitrogen; BMI: Body Mass Index; Cr: Creatinine; DEI: Dietary Energy Intake; DRIs: Dietary Reference Intakes; ESRD: End-Stage Renal Disease; ER: Energy Requirement; GNRI: Geriatric Nutritional Risk Index; Hct: Hematocrit; HD: Hemodialysis; Hb: Hemoglobin; HE: High Energy; HP: High Protein; HOMA-IR: Homeostasis Model Assessment of Insulin Resistance; K/DOQI: Kidney Disease Outcomes Quality Initiative; LE: Low Energy; LP: Low Protein; NKF: National Kidney Foundation; nPNA: Normalization of Protein Equivalent of total Nitrogen Appearance (nPNA); PD: Peritoneal Dialysis; P: Phosphate; K: Potassium; PEW: Protein-Energy Wasting; RRT: Renal Replacement Therapy; Alb: Serum Albumin; HEMO: The National Institutes of Health-Sponsored Hemodialysis; TC: Total Cholesterol; TG: Triglyceride; USRDS: United States Renal Data System; WBC: White Blood Cell Count


In the 2014 United States Renal Data System (USRDS) annual data report, it was showed that the size of the prevalent dialysis population (HD and Peritoneal Dialysis (PD)) increased 3.8 percent in 2012, and is now 57.4 percent larger than in 2000. In 2012, nearly 90 percent of all dialysis patients received HD. Among incident end-stage renal disease (ESRD) patients starting Renal Replacement Therapy (RRT) by HD in 2012, 84.0% had Medicare coverage [1]. In Taiwan, the total number of HD patients in 2011 was 57615 – a 3.1 percent increase from 2010 [2]. In the National Health Insurance Statistics, 2011, it was also showed broken down by the global budget payment system, the outpatient benefits claimed by dialysis was being the highest of all [3]. Because of HD population growing year by year, it would be a danger to national health and increase the burden of medical cost.

Adequate nutrition support in HD patients is one of the most important factors of increased longevity, decreased hospitalization and burden of medical cost. The NKF K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure has referenced several studies [4-8] and developed age-specific guidelines for Dietary Energy Intake (DEI) in HD patients. The recommended DEI is 30 to 35 kcal/kg/day for HD patients = 60 years old and 35 kcal/kg/day for HD patients < 60 years old [5,9,10]. However, data of the National Institutes of Health-sponsored Hemodialysis (HEMO) study (n = 1397) which compared the DEI in patients of various ages determined that the mean DEI was lower than that recommended by the K/DOQI [11], which is similar with studies of Bossola et al. and As’habi et al. [12,13]. Hung and Tarng observed that the mean DEI of Taiwanese HD patients are lower than K/DOQI energy recommendation, but not in malnutrition status [14]. Moreover, the same groups asserted that if DEI exceeds the current recommendations, it could increase adiposity and inflammation [14]. Several studies in Taiwan and Japan have determined that the range of DEI in HD patients is approximately 25–29 kcal/kg/day [14-16]. Considering the DEI less than recommendation, Milano et al. concluded that energy supplementation alone in HD patients resulted in an increase in body weight because of an increase in body fat; however, the nutritional status of the patients did not improve [17]. In summary, the DEI of HD patients commonly ranges from 21 to 29 kcal/kg/day.

The causes of the increased death rates in HD patients are multifaceted. Protein-energy wasting (PEW) is a common phenomenon in patients undergoing dialysis and a risk factor for poor clinical outcomes [18-20]. Such is the case of the “obesity paradox,” whereby a high body mass index (BMI) or body weight gain has been associated with longer survival in many studies [21-23] but not all studies [24-27] of dialysis patients. Chazot et al. concluded that despite overweigh and obese patients on maintenance HD carry a significant lower mortality risk than patients in the normal and lower BMI ranges, but also increased comorbidities [22]. Amongst these, to provide optimal nutrition care to HD patients, a clear understanding of their energy requirements is paramount [28].

Humans require adequate energy to maintain their body temperature and metabolic conditions and to expend energy during physical activities. Energy is regulated by a complex set of feedback mechanisms. Changes in energy intake or expenditure trigger metabolic and behavioral responses that restore the balance of energy in adults [29]. Stability of body weight and body composition requires that energy intake matches energy expenditure and that nutrient balance is achieved [30,31].

Because of the energy recommendations of the 2012 edition of the Dietary Reference Intakes (DRIs) in Taiwan [32,33] are lower than those in the United States [34,35], may be the energy recommendations of the K/DOQI are higher than necessary for Taiwan HD patients. In this study, we established the energy calculate equation and estimate Appropriate Energy Requirements (AER) for Taiwanese HD patients.

Materials and Methods

Study design

This was a cross-sectional observation study and it comprising patients recruited from August 2010 to March 2011. The demographic, anthropometric, and laboratory measurement data of the patients were obtained from a chart review, and the dietary data were obtained from the 3-day dietary records at baseline and followup (Month 2) periods of the current study. We derived an equation of energy prediction to calculate the AER (Figure 1). And we compared the nutritional parameters and dietary data at the baseline and followup period to determine whether the proposed AER was appropriate for maintaining a positive nutritional status. The study was approved by the Institutional Review Board of the Taipei Medical University (NO: 201005004, NO: 99053). All participants provided their written consent.