Nutrition inHemodialysis.

A 55-year-old gentleman has been on hemodialysis three times a week for 8 years for CKD of unknown cause, with hypertension and coronary artery disease. His access is a left radiocephalic fistula. He is anuric; interdialytic weight gain is 2–2.5 kg. He has osteoporosis on DXA at the spine and hip, and high-turnover bone disease with severe secondary hyperparathyroidism. He has lost 8 kg and now weighs 45 kg; height 165 cm (BMI 16.5).

He avoids dal, milk, meat, curd, egg, fruit, and coconut water. He eats a rice-based diet and a few vegetables after leaching. 3-day recall: protein 30 g/day (0.67 g/kg), energy 1,100 kcal/day (24 kcal/kg).

He was started on sevelamer 400 mg three times a day, cinacalcet calcium carbonate 500 mg three times a day (500 mg elemental calcium). He is unwilling to undergo a parathyroidectomy.

Investigations

The tale of two patients. These are the clinical details of two patients on maintenance hemodialysis.

A 79-year-old gentleman, a known diabetic for 21 years, was on insulin for the last 7 years, with moderate non-proliferative diabetic retinopathy. He was hypertensive for the past 7 years and had HFrEF (EF 35%) for 1 year. He has had BPH treated with tamsulosin and was diagnosed with CKD 5 years ago.

In September 2025, he presented with cough, pedal edema, and orthopnea: urea 226 mg/dL, creatinine 7.5 mg/dL, Hb 8.4 g/dL, and urine output 1–1.5 L/day. A left radiocephalic fistula created in December 2025 had primary failure, and he was initiated on hemodialysis in January 2026 through a right IJV catheter, which was later changed to a tunneled catheter. He was on thrice-weekly HD. Residual urine output is 300 to 500 mL/day, and interdialytic weight gain is 1 to 1.5 kg. HbA1c is 6.2%. He is on premixed insulin 30/70: 20 units before breakfast and 12 units before dinner, the same dose as pre-dialysis. A 14-day CGM shows glucose below 70 mg/dL on 4 of 6 dialysis days, mostly in the third hour of dialysis and overnight after dialysis. He felt only sweaty, with no palpitations or tremors.

He had two near-falls in the last 3 months and fractured his left wrist recently. He is on a diabetic diet and avoids dal, meat, milk, and fluids less than 1 litre per day. 3-day recall: protein 30 g/day (0.6 g/kg), energy 900 kcal/day (18 kcal/kg). He generally eats less, so his family asks for an “appetite tonic” and a sleeping pill; he sleeps 4 hours a night. He now needs help to walk and to bathe, has hypotension in most sessions, and takes 12 hours to recover after dialysis. A new fistula is being planned. His son asks how long dialysis should continue.

On examination: weight 50 kg, height 168 cm, BMI 17.72. BP 114/70 mmHg, HR 92/min, no edema.