Similar improvements in serum albumin with intradialytic ONS (~500 kcal, 15 g protein) were reported in an earlier study by Sharma et al (J Ren Nutr. 2002;12:229-237) that compared the nutritional effect and acceptability of providing a home-prepared (HP) or commercial (CNS) high-calorie/protein supplement at dialysis vs. diet counseling alone. Supplements were provided thrice weekly for one month after HD treatment in addition to daily dietary recommendations of 1.2 g/kg protein and 35-45 kcal/kg.

Subjects receiving ONS, either HP (16 patients) or CNS (10 patients), achieved significantly improved mean serum albumin (3.4 to 4.0 and 3.9 g/dL, respectively) compared with 14 controls (3.4 to 3.5 g/dL). Dry weight and BMI increased in the HP and control groups and remained stable with CNS. Mean phosphorus increased for all groups, significantly with CNS. Functional scores (Karnofsky index) increased significantly with ONS vs. control, and ONS was rated acceptable with no adverse effects.

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Although results seem to support using dialysis as an opportunity to provide patients with nutritional supplementation, studies are generally small and short term, and they differ with respect to the type of supplement used and how it is provided. Generalizability of results is limited by exclusion of patients with common non-nutritional factors related to hypoalbuminemia and weight loss in MHD patients, as well as singularity of race in the study by Pupim and colleagues in which subjects were solely African American.

Also, the study by Sharma et al excluded patients with diabetes, a comorbidity found in almost 50% of incident dialysis patients. While study results show promise, there is thus far a lack sufficient follow-up to detect impacts of ONS on morbidity and mortality.

Generally, as a means of addressing malnutrition, intradialytic ONS is well tolerated and may improve serum albumin in otherwise stable MHD patients and assist in achieving National Kidney Foundation  Kidney Disease Outcomes Quality Initiative nutrition recommendations for a daily intake of 1.2 g/kg of protein and 30-35 kcal/kg.

Further study is needed with randomized controlled trials of larger sample size and longer duration to determine the optimal ONS composition and delivery (i.e., intradialytic vs. home use) as well as potential effects on overall health outcomes in MHD patients.