An international panel of 8 nephrologists and 3 dietitians developed practical guidance on implementing oral nutritional supplementation (ONS) and intradialytic parenteral nutrition (IDPN) in adults on maintenance dialysis (hemodialysis and peritoneal dialysis), using consensus voting after structured review of available evidence.
The group reached 20 consensus statements and 34 practice points. Key thresholds include: screen all dialysis patients at least every 3 months; start ONS when spontaneous intake cannot meet needs after counseling (target ~250–300 kcal/day); initiate IDPN when oral + ONS intake still falls short but spontaneous intake exceeds 50% of requirements; prescribe IDPN for 3.5–4 hour sessions with a stepped volume increase. Fish oil supplementation (4 capsules/day) in the PISCES trial reduced serious cardiovascular events by ~40% (HR 0.57, 95% CI 0.47–0.70) in hemodialysis patients.
- All statements are expert consensus, not derived from high-quality RCTs; most IDPN trials are small, heterogeneous, and lack standardized endpoints. - The entire expert group received honoraria and travel support from Fresenius Kabi, the manufacturer of IDPN products, creating a significant conflict of interest. - Guidance covers only ONS and IDPN; enteral nutrition and total PN are addressed only briefly.
Screen every dialysis patient for protein-energy wasting at least quarterly using MIS or SGA, and escalate support stepwise: counseling → ONS → IDPN (or enteral nutrition) based on intake adequacy and PEW severity. When starting IDPN, use a gradual step-up infusion approach and monitor glucose, triglycerides, electrolytes, and volume status closely at each session, especially in the first two weeks.
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