Intradialytic Nutrition and Hemodialysis Prescriptions: A Personalized Stepwise Approach

Single-pool model urea clearance index is associated with sarcopenia and nutritional status in patients undergoing maintenance hemodialysis: a cross-sectional study

BACKGROUND

The single-pool model urea clearance index (single-pool Kt/Vurea; spKt/V) is the most commonly used method for dialysis adequacy assessment. However, only a few studies have examined the relationship between spKt/V values and parameters related to sarcopenia and nutritional status. This study aimed to evaluate whether the spKt/V is an indicator of sarcopenia and nutritional status in patients undergoing maintenance hemodialysis (MHD).

METHODS

A total of 142 patients were included in this single-center, cross-sectional study. Venous blood samples were collected shortly before the hemodialysis session. The adequacy of dialysis in patients receiving MHD was assessed using spKt/V. Sarcopenia was identified according to the Asian Working Group for Sarcopenia (2019) definition. Receiver operating characteristic curve and area under the curve were used to evaluate the predictive value of spKt/V in sarcopenia. Univariate and multivariate binary logistic regression analyses were used to determine the association between spKt/V and sarcopenia and nutritional status.

RESULTS

The mean spKt/V level was 1.3 ± 0.2, the prevalence of sarcopenia was 15.5% in patients on MHD. The best cutoff value of spKt/V in sarcopenia was 1.45 for both sexes, 1.33 and 1.45 for men and women, respectively (P < 0.05). The multivariate binary logistic regression shown that the spKt/V was independently positively associated with sarcopenia (OR = 122.88, 95% CI = 0.64-0.87, P = 0.002). Grouping spKt/V by the best cutoff value, when spKt/V ≥ 1.45, the OR of sarcopenia was 11.75 (95% CI = 3.16-43.67, P < 0.001). Subgroup analyses showed that when spKt/V ≥ 1.33 in men and spKt/V ≥ 1.45 in woman, the OR of sarcopenia was 9.73 (95% CI = 2.25-42.11, P = 0.002) and 14.52 (95% CI = 1.06-199.67, P = 0.045), respectively.

CONCLUSIONS

The present study showed that spKt/V was an important influencing factor of sarcopenia and malnutrition in Asian patients on MHD.

Adaptive Nutrition Intervention Stabilizes Serum Phosphorus Levels in Hemodialysis Patients: A Multicenter Decentralized Clinical Trial Using Real-World Data

OBJECTIVE

This study aims to evaluate the effect of an adaptive nutritional and educational intervention for patients on hemodialysis (HD) in a routine care setting, using real-world data from electronic health records.

METHODS

Decentralized clinical trial of seven HD facilities recruited patients who have been on HD for over 3 months (N = 153) for an 8-week adaptive intervention protocol. Patients were divided into four groups: (1) control (2) education intervention (3) meal intervention (4) education and meal interventions. Educational contents were digitally delivered via mobile phones and premade meals tailored on laboratory findings were home-delivered. Changes in serum electrolytes and malnutrition inflammation score (MIS) were analyzed.

RESULTS

Meal intervention statistically significantly stabilized serum phosphorus level (β = -0.81 mg/dL, 95% confidence interval = [-1.40, -0.22]) at week 8, with increased likelihood of being within target serum value range (odds ratio = 1.21, 95% confidence interval = [1.04, 1.40]). Meal group showed better nutritional status (MIS = 3.65) than the education group (MIS = 5.10) at week 8 (adjusted p < .05). No significant changes were observed in serum potassium level, depression, and self-efficacy.

CONCLUSION

It was demonstrated that an adaptive meal intervention in a real-world care setting may benefit serum phosphorus control and nutritional status of patients on HD, without negative effect on depression levels or self-efficacy. More work is needed to develop an effective educational intervention.

Revisiting Intradialytic Parenteral Nutrition: How Can We Apply the Evidence in Clinical Practice?

Intradialytic parenteral nutrition (IDPN) remains a controversial nutrition support practice in hemodialysis. Multiple reviews and evidence-based clinical practice guidelines have been published in the past 20 years. Despite essentially looking at the same evidence, conclusions and recommendations vary significantly, leading to widespread uncertainty among clinicians on the value of and indications for IDPN. This paper aims to bring a clinical perspective to the current state of evidence and clinical practice, recognizing the strengths and weaknesses of current evidence and the clinical questions that remain unanswered, as well as providing guidance for using IDPN in clinical practice. IDPN should be considered a strategy to complement spontaneous oral intake in clinically stable patients receiving maintenance hemodialysis or who have or are at risk of malnutrition and who have substantial but not adequate protein and/or energy intake. There is a clear need for robust randomized controlled trials evaluating the impact of IDPN in appropriately selected patients. Additionally, future trials should include patient-centered outcome measures such as appetite, spontaneous oral intake, quality of life, and reliable measures of nutritional status.

Effects of oral nutritional supplements on the nutritional status and inflammatory markers in patients on maintenance dialysis: a systematic review and meta-analysis of randomized clinical trials

Background and aims

Patients on hemodialysis (HD) or peritoneal dialysis (PD) often have insufficient energy and protein intake, resulting in poor nutritional status and adverse outcomes. Oral nutritional supplements (ONSs) are the most commonly used to increase such patients' energy and protein intakes.

Methods

In this systematic review and meta-analysis, we analyzed studies on nutritional status, inflammatory markers, and electrolyte levels in patients on dialysis receiving ONSs. We searched four electronic databases from inception until 31 December 2022, for randomized controlled trials comparing ONS treatment versus placebo or routine care.

Results

22 studies with 1185 patients on dialysis were included in our meta-analysis. Compared with the control group, the ONS group exhibited significantly increased serum albumin levels [1.26 g/l (95%CI, 0.50-2.02, P < 0.0001; I2 = 80.4%)], body mass indexes (BMIs) [0.30 kg/m2 (95%CI, 0.09-0.52, P = 0.005; I2 = 41.4%)], and handgrip strength (HGS) [0.96 kg (95%CI, 0.07-1.84, P = 0.034; I2 = 41.4%)] from baseline to the end of intervention. No significant differences were observed between the groups in lean body mass, phase angle, C-reactive protein, and serum phosphorus and potassium levels. In terms of improving albumin, the subgroup analyses show that ONS use seems to be more inclined to three variations: HD patients, short-term use, and non-intradialytic supplementation.

Conclusion

In conclusion, ONS use can improve the nutritional status of patients on dialysis in terms of their serum albumin, BMI, and HGS without significant effects on serum phosphorus, potassium, and C-reactive protein levels. However, it remains uncertain whether these results translate to improvement in clinically relevant outcomes. Large-scale high-quality studies are still required in this population.

Short-Term Effects of a Therapeutic Diet on Biochemical Parameters in Hemodialysis Patients: A Randomized Crossover Trial

OBJECTIVE

Although unhealthy diets exacerbate nutritional and metabolic derangements in patients with end-stage kidney disease (ESKD), how therapeutic diets that possess a variety of different dietary strategies acutely modify diverse biochemical parameters related to cardiovascular disease remains underexplored.

METHODS

Thirty-three adults with end-stage kidney disease undergoing thrice-weekly hemodialysis participated in a randomized crossover trial comparing a therapeutic diet with their usual diets for 7 days, separated by a 4-week washout period. The therapeutic diet was characterized by adequate calorie and protein amounts, natural food ingredients with a low phosphorus-to-protein ratio, higher portions of plant-based food, and high fiber content. The primary outcome measure was the mean difference in the change-from-baseline intact fibroblast growth factor 23 (FGF23) level between the 2 diets. The other outcomes of interest included changes in mineral parameters, uremic toxins, and high-sensitivity C-reactive protein (hs-CRP) levels.

RESULTS

Compared with the usual diet, the therapeutic diet lowered intact FGF23 levels (P = .001), decreased serum phosphate levels (P < .001), reduced intact parathyroid hormone (PTH) levels (P = .003), lowered C-terminal FGF23 levels (P = .03), increased serum calcium levels (P = .01), and tended to lower total indoxyl sulfate levels (P = .07) but had no significant effect on hs-CRP levels. Among these changes, reduction in serum phosphate level achieved in 2 days, modifications of intact PTH and calcium levels in 5 days, and reductions in intact and C-terminal FGF23 levels in 7 days of therapeutic diet intervention.

CONCLUSION

Within the 1-week intervention period, the dialysis-specific therapeutic diet rapidly reversed mineral abnormalities and tended to decrease total indoxyl sulfate levels in patients undergoing hemodialysis but had no effect on inflammation. Future studies to assess the long-term effects of such therapeutic diets are recommended.

Prevalence of Dental Caries in Patients on Renal Replacement Therapy-A Systematic Review

Patients under renal replacement therapy (RRT) often show oral problems, including dry mouth, periodontal and dental diseases. This systematic review aimed to evaluate the caries burden in patients on RRT. Therefore, a systematic literature search based on the databases PubMed, Web of Science and Scopus was performed by two independent individuals in August 2022. Search terms were: "caries" AND "dialysis", "caries" AND "renal replacement therapy", "caries" AND "kidney". The systematic process was complemented by manual search. Studies on adult patients (age ≥ 18 years), treated by any form of RRT and explicitly reporting caries prevalence or incidence were checked for their eligibility and subsequently analyzed qualitatively. For all included studies, a quality appraisal was applied. From the systematic search, 653 studies were identified, of which 33 clinical investigations were included in the qualitative analysis. The majority (31 studies) of all included patients underwent hemodialysis (HD), with a sample size between 28 and 512 participants. Eleven studies investigated a healthy control group. Oral examinations were heterogeneous across studies; the caries burden was primarily assessed by decayed-(D-T), missing- and filled-teeth index (DMF-T). The number of decayed teeth ranged between 0.7 and 3.87 across studies. Only six out of these 11 studies found significant differences in caries prevalence/incidence between RRT and controls, whereby only four studies confirmed worse caries burden in RRT individuals. No information was provided on caries stadium (initial caries, advanced caries, invasive treatment need), caries activity or location (e.g., root caries) across studies. Most of the included studies were assessed to be of moderate quality. In conclusion, patients on RRT suffer from a high prevalence of dental caries. Alongside a need for further research in the field, improved, multidisciplinary, patient-centered dental care concepts are required to support dental and overall oral health in individuals on RRT.

Utility of a modified Controlling Nutritional Status score in mortality risk assessment of patients on hemodialysis

PURPOSE

Malnutrition is common among hemodialysis patients. A nutritional index may be important for their prognosis prediction. We examined the use of a modified version of the Controlling Nutritional Status (CONUT) score as a predictor of mortality in hemodialysis patients and investigated whether statin use modified the association.

METHODS

We conducted a retrospective cohort study in 1130 adults (mean age 67.7 years, 35.0% women) on maintenance hemodialysis at four outpatient dialysis clinics in Japan. The exposure of interest was modified CONUT scores calculated by one-time data of serum albumin and total cholesterol at baseline, or mean data of these measures using multiple blood test results. The primary outcome was all-cause mortality. We examined the association between modified CONUT groups (low-risk, middle-risk, and high-risk) and mortality using multivariate Cox proportional hazard regression and logistic regression models in overall patients and by statin use.

RESULTS

During a median follow-up of 6.6 years, 525 (46.5%) patients died. Analysis using both one-time and mean data showed increased mortality risk in the high-risk modified CONUT score group as compared to the low-risk group (mean data: HR 2.52, 95% CI 1.96, 3.24); when stratified by statin use, the effect appeared stronger among users (mean data: HR 5.84, 95% CI 2.98, 11.44). Strong predictive ability was observed, particularly for mortality risk at 5 year follow-up using mean data (AUC = 0.842).

CONCLUSION

Our results suggest that the modified CONUT score may be useful in helping clinicians quickly identify hemodialysis patients with poorer prognosis who may benefit from close monitoring and interventions.

Comparison of the prevalence and associated factors of cognitive frailty between elderly and middle-young patients receiving maintenance hemodialysis

PURPOSE

This study aimed at comparing the prevalence of cognitive frailty and explore the differences in the influencing factors between elderly and middle-young patients receiving maintenance hemodialysis (MHD).

METHODS

In this cross-sectional study, the frailty phenotype, mini-mental state examination, and clinical dementia rating were used to assess the current status of cognitive frailty in 852 patients receiving MHD from four hospitals in Lianyungang City and Xuzhou City, Jiangsu Province, China; the influencing factors were then analyzed for statistical significance.

RESULTS

Of the total 852 patients receiving MHD, 340 were classified into an elderly group (≥ 60 years) and 512 into a middle-young group (< 60 years). The prevalence of cognitive frailty was 35.9% and 8.8%, respectively. The results of multivariate logistic regression analysis showed that the independent factors of cognitive frailty were age (P < 0.001), education level (P = 0.010), nutritional status (P = 0.001), serum albumin level (P = 0.010), calf circumference (P = 0.024), and social support level (P < 0.001) in the elderly group and comorbidity status (P = 0.037), education level (P < 0.001), nutritional status (P = 0.008), serum creatinine level (P = 0.001), waist circumference (P < 0.001), and depression (P = 0.006) in the middle-young group.

CONCLUSION

The prevalence of cognitive frailty was significantly higher in the elderly group than in the middle-young group, and the influencing factors differed between the two populations.

Incremental and Personalized Hemodialysis Start: A New Standard of Care

Introduction

Incremental hemodialysis (iHD) may attenuate “dialysis shock” and reduce costs, preserving quality of life. It is considered difficult to reconcile with HD wards’ routine; fear of underdialysis and increasing mortality are additional concerns. The aim of this study was to evaluate mortality, morbidity, and costs in a large HD ward where iHD is the standard of HD start.

Methods

This observational study included all incident HD patients in 2017 to 2021, stratified according to HD start: iHD (1–2 sessions/wk), decremental HD (dHD, 3 sessions/wk at start, later reduced), or standard (3 sessions/wk). Results were compared with data recorded in the same unit before the incremental program (2015–2017) and with a propensity score-matched cohort from the French Renal Epidemiology and Information Network (REIN) registry.

Results

A total of 158 patients started HD in 2017 to 2021, 57.6% on iHD, 8.9% dHD, and 33.5% standard HD schedule. Patients on the standard schedule had lower initial estimated glomerular filtration rate (eGFR) (5 vs. 7 ml/min per 1.72 m², P = 0.003). We found no survival differences according to period of start (same center) and propensity score matching (REIN). Patients intensively followed in the pre-HD period were more likely to start on iHD-dHD. Persistence on iHD-dHD was about 50% at 1 year and 35% at 2 years. Hospitalization rates and time to first hospitalization or death did not differ between the schedules. The iHD-dHD policy allowed a 16% cost saving, even accounting for supplemental biochemical tests.

Conclusion

Our study reveals that iHD can be a new standard of care, as it is safe and feasible in up to two-thirds of patients on incident HD.

When is parenteral nutrition indicated?

The indications and contraindications of parenteral nutrition (PN) are discussed in view of recent clinical findings. For decades, PN has been restricted to patients unable to tolerate enteral nutrition (EN) intake owing to the perceived risk of severe side-effects. The evolution of the PN substrate composition and delivery of nutrition via all-in-one bags has dramatically improved the application prospects of PN. Recent studies show similar complication rates of nutrition therapy administered through enteral and intravenous routes. Therefore, indications of PN have, based on evidence, extended beyond complete gastrointestinal (GI) failure to include conditions such as insufficient EN generating persistent negative energy balance and insufficient protein intakes, malabsorption, or specific needs that are impossible to cover with EN feeds.

Zinc Deficiency, Plasma Fatty Acid Profile and Desaturase Activities in Hemodialysis Patients: Is Supplementation Necessary?

Background: Desaturation and elongation are critical processes in endogenous metabolic fatty acid pathways. Zinc (Zn) is a cofactor for desaturases and elongases enzymes. There is limited evidence regarding the relationships between biomarkers of Zn status, nutritional intake, plasma phospholipid fatty acid profile and clinical outcomes among patients undergoing hemodialysis (HD). Objective: To examine the relationships between dietary and serum levels of Zn and Cu/Zn ratio and to explore associations of these micronutrients with PUFA profile and estimated desaturase and elongase enzyme activities in serum phospholipids among HD patients. Methods: This study included 40 adult patients undergoing hemodialysis treatment. Repeated 24-h recalls were applied for dietary intake assessment. Serum concentration of Zn and Cu were determined using inductively coupled plasma mass spectrometry and fatty acid composition by gas-liquid chromatography. Desaturase and elongase activities were calculated from product-precursor fatty acid ratios. Results: Inadequate dietary Zn intake was found in 55% of HD patients. They all had serum Zn concentration below the reference value of 60 μg/dL (mean 38.8 ± 7.72 μg/dL). Adequate zinc intake was accompanied with significantly higher intake of energy, total fats, SFA, MUFA and proteins. There was no correlation between Zn serum status and Zn intake estimates. Serum Cu/Zn ratio was high, (2.76 ± 0.68), directly and significantly associated with HD period, CRP, BMI, VFA, and inversely with Kt/V, albumin, iron, and iPTH. The n-6/n-3 ratio in plasma phospholipids was elevated (12.25 ± 3.45) and patients with inadequate Zn intake had lower n-3 PUFA intake and status compared to those with adequate intake. Serum Zn concentrations were inversely correlated with linoleic/dihomo-γ-linolenic acid ratio (LA/DGLA) (p = 0.037), related to D6-desaturase activity (p = 0.033) and directly with DGLA relative abundances (p = 0.024). Cu status was inversely associated with EPA level (p = 0.03) and estimates of elongase activity (p = 0.001). Furthermore, positive relationship was found between the Cu/Zn ratio and determined elongase value (p = 0.01). Conclusion: Findings of this study underpin the high prevalence of Zn deficiency and inadequate n-3 PUFA intake and status among subjects undergoing HD. The results obtained indicate that the assessment of Zn status should be a standard parameter of nutritional status screening in HD patients while emphasizing the importance of Cu/Zn determination. Although further research is warranted, Zn and-n-3 PUFA supplementation in HD patients might be beneficial for the prevention and attenuation of adverse health outcomes.

Toward an individualized determination of dialysis adequacy: a narrative review with special emphasis on incremental hemodialysis

INTRODUCTION

The search for the 'perfect' renal replacement therapy has been paralleled by the search for the perfect biomarkers for assessing dialysis adequacy. Three main families of markers have been assessed: small molecules (prototype: urea); middle molecules (prototype β2-microglobulin); comprehensive and nutritional markers (prototype of the simplified assessment, albumin levels; composite indexes as malnutrition-inflammation score). After an era of standardization of dialysis treatment, personalized dialysis schedules are increasingly proposed, challenging the dogma of thrice-weekly hemodialysis.

AREAS COVERED

In this review, we describe the advantages and limitations of the approaches mentioned above, focusing on the open questions regarding personalized schedules and incremental hemodialysis.

EXPERT OPINION

In the era of personalized dialysis, the assessment of dialysis adequacy should be likewise personalized, due to the limits of 'one size fits all' approaches. We have tried to summarize some of the relevant issues regarding the determination of dialysis adequacy, attempting to adapt them to an elderly, highly comorbidity population, which would probably benefit from tailor-made dialysis prescriptions. While no single biomarker allows precisely tailoring the dialysis dose, we suggest using a combination of clinical and biological markers to prescribe dialysis according to comorbidity, life expectancy, residual kidney function, and small and medium-size molecule depuration.

Consensus on the standard terminology used in the nutrition care of adult patients with chronic kidney disease

This nutrition consensus document is the first to coordinate the efforts of three professional organizations - the Brazilian Association of Nutrition (Asbran), the Brazilian Society of Nephrology (SBN), and the Brazilian Society of Parenteral and Enteral Nutrition (Braspen/SBNPE) - to select terminology and international standardized tools used in nutrition care. Its purpose is to improve the training delivered to nutritionists working with adult patients with chronic kidney disease (CKD). Eleven questions were developed concerning patient screening, care, and nutrition outcome management. The recommendations set out in this document were developed based on international guidelines and papers published in electronic databases such as PubMed, EMBASE(tm), CINHAL, Web of Science, and Cochrane. From a list of internationally standardized terms, twenty nutritionists selected the ones they deemed relevant in clinical practice involving outpatients with CKD. The content validity index (CVI) was calculated with 80% agreement in the answers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess the strength of evidence and recommendations. A total of 107 terms related to Nutrition Assessment and Reassessment, 28 to Diagnosis, nine to Intervention, and 94 to Monitoring and Evaluation were selected. The list of selected terms and identified tools will be used in the development of training programs and the implementation of standardized nutrition terminology for nutritionists working with patients with chronic kidney disease in Brazil.

The effects of the transtheoretical model combined with nutritional intervention in hemodialysis patients

OBJECTIVE

To investigate the effects of the transtheoretical model combined with nutritional intervention (TTMNI) in hemodialysis (HD) patients.

METHODS

The clinical data of 100 HD patients recorded from October 2018 to October 2020 were retrospectively collected and divided into two groups according to the intervention method each patient underwent. Group A (n=49) underwent routine nursing intervention and group B (n=51) underwent TTMNI combined with routine nursing intervention. The two groups were compared before and after intervention in terms of their nutritional indices, Renal Adherence Attitudes Questionnaire (RAAQ) scores, their Renal Adherence Behavior Questionnaire (RABQ) scores, their Subjective Global Assessment (SGA) statuses, their anthropometric indicators such as their serum creatinine (SCr), blood urea nitrogen (BUN), mid-arm muscle circumference (MAMC), triceps skinfold (TSF), body mass index (BMI), urea clearance index (KT/V), and urea reduction ratios (URR%).

RESULTS

Compared with group A, group B showed higher transferrin (TRF), prealbumin (PA), and albumin (ALB) levels, higher RAAQ and RABQ scores, higher MAMC, TSF, and BMI levels and lower SGA scores, and lower SCr, and BUN levels (P<0.05). After the intervention, the attainment rate of target KT/V was 94.12% in group B, higher than the 63.27% in group A, and the patients with target URR% accounted for 96.07% in group B, higher than the 61.22% in group A (P<0.05).

CONCLUSION

TTMNI for HD patients is helps improve patients' nutritional statuses and their dietary compliance as well as their liver function, and it increases their dialysis attainment rate.

[Prevalence and risk factors associated with intradialytic hypotension in Sub-Saharan Africa: The case of Burkina Faso]

AIM

The aim of our study was to determine the prevalence and factors associated with intradialytic hypotension in our cohort of chronic hemodialysis patients.

METHODS

This was a prospective monocentric study over a six-month period. Intradialytic hypotension was defined as a decrease in systolic blood pressure ≥ 20mmHg or a decrease in mean arterial pressure of 10mmHg associated with clinical events and the need for nursing interventions. The groups were compared using univariate analysis of variance.

RESULTS

We included 48 patients and counted 3014 hemodialysis sessions. The mean age was 44.7±15 years. The prevalence of intradialytic hypotension was 12.4%, with cramps 20 (41.7%) as the main symptom. Factors associated with frequent intradialytic hypotension compared to the groups without intradialytic hypotension and with infrequent intradialytic hypotension were age (61±13 years, p=0.018), diabetes (33.3%, p=0.019), high body mass index (27, 3±7.8kg/m2, p=0.002), interdialytic weight gain ≥ 5% of baseline weight (66.7%, p=0.033), hourly ultrafiltration (800±275ml/h, p=0.037) and perdialytic feeding (33.3%, p=0.016). Low pre-dialysis diastolic blood pressure (72±13mmHg, p=0.012) and high baseline weight (73.9±17.5kg, p=0.028) were associated with frequent versus infrequent intradialytic hypotension.

CONCLUSION

Intradialytic hypotension is common in our context. Its prevention in at-risk patients is critical to reducing morbidity and mortality and improving quality of life.

Hemodialysis-Nutritional Flaws in Diagnosis and Prescriptions. Could Amino Acid Losses be the Sharpest "Sword of Damocles"?

This review aims to highlight the strengths and weaknesses emerging from diagnostic evaluations and prescriptions in an intent to prevent progression over time of malnutrition and/or protein-energy wasting (PEW) in hemodialysis (HD) patients. In particular, indications of the most effective pathway to follow in diagnosing a state of malnutrition are provided based on a range of appropriate chemical-clinical, anthropometric and instrumental analyses and monitoring of the nutritional status of HD patients. Finally, based on the findings of recent studies, therapeutic options to be adopted for the purpose of preventing or slowing down malnutrition have been reviewed, with particular focus on protein-calorie intake, the role of oral and/or intravenous supplements and efficacy of some classes of amino acids. A new determining factor that may lead inexorably to PEW in hemodialysis patients is represented by severe amino acid loss during hemodialysis sessions, for which mandatory compensation should be introduced.

Eating during the Hemodialysis Session: A Practice Improving Nutritional Status or a Risk Factor for Intradialytic Hypotension and Reduced Dialysis Adequacy?

Historically, eating during the hemodialysis treatment has been associated with increased risk for adverse intradialytic symptoms and events, risks that have resulted in the implementation of restrictive in-center nutrition policies. Recent studies, however, have recorded a shift in clinical practice with a higher proportion of physicians following the view that administration of intradialytic meals and supplements represents a simple and effective approach to enhance caloric intake and improve nutritional status among patients on hemodialysis. This shift towards less restrictive in-center nutrition practices is mainly supported by evidence from observational studies associating intradialytic nutritional supplementation with improvements in protein-energy wasting, inflammatory state, and health-related quality of life. In sharp contrast, earlier and recent interventional studies have documented that feeding during the hemodialysis treatment provokes a rapid postprandial decline in blood pressure and raises the incidence of symptomatic intradialytic hypotension. Furthermore, other studies have shown that postprandial redistribution in intravascular volume and enhanced blood supply to the gastrointestinal circulation may interfere with the adequacy of the delivered hemodialysis. Those who defend the position that intradialytic nutritional support is beneficial do not dispute the physiology of postprandial hemodynamic response, but they argue against its clinical significance. In this article, we provide an overview of studies that explored the effect of eating during the hemodialysis treatment on intradialytic hemodynamic stability and adequacy of the delivered hemodialysis. We reason that these risks have important clinical implications that are not counteracted by anticipated benefits of this strategy on caloric intake and nutritional status.