Nutritional considerations and the indications for dialysis.

Evidence of a reduction in dietary protein intake and some indices of nutritional status in chronic renal failure (CRF) patients consuming unrestricted diets has led some individuals to recommend that low-protein diets be avoided and that dialysis should be initiated if the protein intake declines below 0.8 g protein/kg/day. However, evidence indicates that when properly implemented, low-protein diets are safe and can maintain lean body mass even during long-term therapy. This is because CRF patients are able to activate normal compensatory responses when protein intake is restricted, and their protein and energy requirements are similar to healthy subjects. Because low-protein diets ameliorate uremic symptoms and some of its metabolic complications, dietary therapy should be attempted in all patients with progressive CRF. The recommendation to initiate dialysis when the protein intake declines below 0.8 g/kg/day should be viewed with skepticism because mortality risk is increased in end-stage renal disease (ESRD) patients and dialysis therapy does not improve protein and energy intake or ameliorate malnutrition.