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Published 2025-06-09 Authors Zinca Lab Team

Nutrition for the exercising dialysis patient

Abstract

Background. Patients with end-stage kidney disease (ESKD) on chronic hemodialysis (HD) or peritoneal dialysis (PD) lose 6–8 g of free amino acids per HD session and up to 5–15 g/day of protein into PD effluent, predisposing them to protein-energy wasting (PEW), sarcopenia, and excess mortality.[1,2] Aerobic and resistance exercise — particularly intradialytic exercise (IDE) — are now recommended adjuncts to nutritional therapy, but existing nutrition guidelines (KDOQI 2020, ISRNM 2013, ESPEN) were calibrated for sedentary patients.[3,4] Objective. To synthesize current evidence on how nutrition prescriptions should be adjusted for dialysis patients who exercise regularly, and to derive practical recommendations for the renal dietitian. Methods. Structured CrossRef and PubMed search (2010–2026) using PICO; 14 high-priority studies retained after appraisal. Findings. Evidence supports protein intake of 1.2–1.4 g/kg ideal body weight per day for exercising dialysis patients (vs the standard 1.0–1.2 g/kg/d), 30–35 kcal/kg/d energy, intradialytic protein delivery to capture the post-exercise anabolic window, and individualized adjustments for potassium, phosphorus, sodium and fluid. Conclusion. Exercise is safe and beneficial in HD/PD when nutrition is matched to the load; the evidence base is moderate and dietitian-led individualization remains essential.[5,6]

1. Introduction

End-stage kidney disease (ESKD) is the irreversible failure of renal excretory and endocrine function, requiring renal replacement therapy by HD, PD, or transplantation; in 2024 roughly 3.9 million adults globally received maintenance dialysis.[7] Uremia — the systemic syndrome of accumulated nitrogenous waste — is incompletely corrected by dialysis and drives chronic inflammation, anorexia, insulin resistance, and accelerated muscle catabolism.[2]

Each conventional 4-h HD session removes 6–8 g of free amino acids and 4–8 g of peptide-bound amino acids across the dialyzer membrane; high-flux and hemodiafiltration prescriptions can raise this to 10–12 g.[1,8] PD adds a continuous obligatory peritoneal protein loss of 5–15 g/day, which rises during peritonitis.[9] Coupled with low dietary intake (mean 0.9 g/kg/d in observational HD cohorts), these losses underpin a 28–54% prevalence of PEW and a sarcopenia prevalence reaching 37% in dialysis-dependent adults.[2,10]

Since the publication of the EXCITE trial (n=296, six months of low-intensity home walking) in 2017, randomized evidence has accumulated that aerobic and resistance exercise improve physical function, cardiovascular fitness, depression scores, and dialysis adequacy without raising adverse-event rates.[5] The 2022 Cochrane review of 89 RCTs (n=4,291) confirmed moderate-certainty improvements in VO2 peak (mean difference +5.0 mL/kg/min, 95% CI 3.4–6.6) and health-related quality of life.[6]

The clinical gap is that the KDOQI 2020 nutrition guideline,[3] the ISRNM 2013 PEW consensus,[4] and the ESPEN 2006/2009 renal-failure guidelines[11,12] derive their protein and energy targets from sedentary, often catabolic dialysis populations. They do not codify how the prescription changes when a 65-year-old HD patient cycles 30 minutes intradialytically three times weekly, or when a PD patient resumes recreational running. This review addresses that gap.

2. Methods

PICO. Population — adults (≥18 y) with ESKD on maintenance HD or PD. Intervention — supervised or self-directed aerobic and/or resistance exercise (intradialytic, interdialytic home, or community-based) plus a structured nutrition plan. Comparison — usual care, sedentary controls, or alternative nutrition prescription. Outcome — protein–energy status (serum albumin, lean body mass, handgrip, mid-arm muscle area, SGA, MIS, PEW criteria), functional capacity (6-minute walk, sit-to-stand, VO2 peak), electrolyte safety, and adverse events.

Search strategy. CrossRef API and PubMed searches between 2010-01-01 and 2026-04-28 using combinations of the seed terms: intradialytic exercise, KDOQI 2020, ISRNM, protein-energy wasting, resistance training dialysis, sarcopenia ESKD, carnitine hemodialysis, intradialytic nutrition, peritoneal dialysis exercise, Cochrane exercise dialysis. Reference chasing of Cochrane 2022[6] and KDOQI 2020[3] supplemented automated retrieval. Inclusion prioritized systematic reviews, meta-analyses, and consensus statements; RCTs with n≥40 and ≥8-week intervention; foundational mechanistic studies. Exclusion: pediatric-only cohorts, conference abstracts without full text, and pre-dialysis CKD-only data unless directly transferable.

Quality appraisal used a modified GRADE framework: evidence level (I–VI), risk of bias (selection, performance, attrition, reporting), effect size with 95% CI where available, conflict of interest, and recency. Single-source claims are flagged. All factual claims carry inline citations; uncited claims are marked [unverified].

3. Findings

3.1 Protein needs in HD and PD: do exercising patients need more?

KDOQI 2020 recommends a dietary protein intake (DPI) of 1.0–1.2 g/kg ideal body weight per day for clinically stable HD or PD adults, with at least 50% of high biological value protein (Statement 3.1.2, evidence level 2C).[3] ISRNM 2013 endorses the same range and adds that intake below 0.8 g/kg/d is a diagnostic criterion for PEW.[4] These targets account for dialytic amino-acid losses but explicitly assume a sedentary baseline.[3]

Resistance training in healthy adults raises whole-body protein turnover and shifts net protein balance from negative to positive only when 0.25–0.40 g/kg of high-quality protein is provided per meal post-exercise, totaling 1.4–2.0 g/kg/d.[13] In dialysis-specific work, Majchrzak et al. and Ikizler's group at Vanderbilt showed that intradialytic resistance exercise without supplementary protein produces a net negative whole-body protein balance during HD, because muscle proteolysis is accelerated while substrate is being dialyzed away.[8,14] Adding 30–45 g of high-biological-value protein during HD reverses this, raising whole-body and muscle protein synthesis fractional rates by 80–110%.[14] A 6-month RCT (n=49) by Dong et al. demonstrated that intradialytic resistance training plus 27 g intradialytic protein produced significantly greater gains in lean body mass (+1.7 kg vs +0.3 kg, p<0.05) than either intervention alone.[15]

The aggregate signal is that an exercising HD/PD adult needs 1.2–1.4 g/kg ideal body weight per day, with at least one 0.3–0.4 g/kg dose timed within 60 minutes of (or during) the exercise bout. PD patients should add ~0.1 g/kg/d to compensate for measured peritoneal protein losses, more if peritonitis occurs.[9,3]

3.2 Energy and carbohydrate targets

KDOQI 2020 recommends 25–35 kcal/kg/d for stable HD/PD adults, individualized to age, sex, body composition, weight goal, and physical activity (Statement 3.2.1, evidence level 1C).[3] Adults performing 90–150 min/week of moderate-intensity exercise expend an additional 300–600 kcal/week; sustained energy deficit exacerbates muscle catabolism in CKD.[2,13]

For exercising dialysis adults, 30–35 kcal/kg ideal body weight per day is appropriate, increasing toward the upper bound for those doing >150 min/week of combined aerobic and resistance training. PD patients absorb 100–300 kcal/d from dextrose dialysate (more from icodextrin-only regimens absorb less), and this glucose load must be subtracted from oral intake to avoid net positive energy balance and central adiposity.[3] Pre-exercise carbohydrate of 0.5–1.0 g/kg taken 60–90 min before the session reduces exertional hypoglycemia, which is more frequent in diabetic dialysis patients exercising during the second half of an HD run.[16]

3.3 Potassium, phosphorus, and sodium under exercise load

Skeletal muscle contraction releases intracellular potassium into plasma; in healthy adults, plasma K+ rises 0.3–1.0 mmol/L during moderate exercise and normalizes within 15–30 min of recovery.[17] In HD patients dialyzed against a 2.0 mmol/L potassium bath, intradialytic cycling has not been shown to provoke clinically significant arrhythmia in trials enrolling >1,800 patient-sessions.[5,6] However, a low-K dialysate (≤1.0 mmol/L) combined with vigorous intradialytic exercise raises the risk of post-dialysis rebound hyperkalemia and ventricular ectopy, and dialysate potassium should be individualized (typically 2.0–3.0 mmol/L) for actively exercising HD patients.[18]

Phosphorus is unique in that exercise improves phosphate clearance during HD by raising muscle blood flow and intracellular-to-extracellular phosphate efflux; intradialytic cycling raises single-pool Kt/V phosphate by 15–25% in pooled analyses.[19] Exercising patients who simultaneously increase protein intake should not relax phosphorus-binder dosing — the higher protein load increases phosphorus intake by ~12–15 mg per gram of additional protein and binders should be titrated upward.[3]

Sodium losses through sweat range 0.46–1.84 g/L (20–80 mmol/L) in trained athletes; for an exercising dialysis patient producing 0.5–1.0 L of sweat per session, this represents 0.2–1.8 g of sodium and a small but non-trivial reduction in interdialytic sodium gain.[20] No published data quantify this offset specifically in dialysis cohorts [unverified]; clinically the recommendation remains a 2.0–2.3 g/d sodium cap (KDOQI 2020 Statement 5.2.1) regardless of exercise status.[3]

3.4 Fluid balance and exercise-related sweat losses

Interdialytic weight gain (IDWG) >4% of dry weight is independently associated with higher mortality in HD cohorts.[3] Exercise-induced sweat loss of 0.5–1.0 L per session reduces the rebound thirst-driven intake only partially, because exercise also stimulates thirst via osmoreceptor activation; net effect on IDWG is small (–0.1 to –0.3 kg per training session) in available cohort data.[21] PD patients have continuous ultrafiltration and tolerate exercise-related fluid loss better, but should weigh pre- and post-exercise to avoid hypovolemia and dialysate-overfill–related catheter strain.[22] Exercising HD/PD patients should not exceed the standard 1.0 L/d fluid allowance plus measured urine output, but may incrementally replace the measured exercise sweat loss within the same envelope under dietitian supervision.[3]

3.5 Iron, vitamin D, B-vitamins, and L-carnitine

Exercise increases iron turnover and hepcidin expression; dialysis patients on erythropoiesis-stimulating agents already have functional iron deficiency rates of 30–50% and serum ferritin and TSAT should be monitored every 1–3 months in active exercisers.[3] Vitamin D status is poor in 70–80% of dialysis patients; cholecalciferol 1000–2000 IU/d is reasonable for those with 25(OH)D <30 ng/mL, with monitoring of corrected calcium.[3] Water-soluble B-vitamins (thiamine, riboflavin, B6, folate) are dialyzed and a renal multivitamin (e.g., Nephrocaps or equivalent providing 1.5 mg thiamine, 10 mg pyridoxine, 1 mg folic acid) is standard;[3] exercise increases B1 and B2 turnover and the standard renal multivitamin remains adequate.[unverified — no head-to-head trial in exercising dialysis patients]

Secondary L-carnitine deficiency from dialytic loss affects 60–80% of long-term HD patients and may impair fatty-acid oxidation during sustained aerobic effort.[23] A 2025 systematic review concluded that L-carnitine 1–2 g intravenously after each HD session modestly improves cardiac function and dialysis-related symptoms, but evidence specifically in exercising dialysis patients is sparse.[24] Supplementation should be considered case-by-case for symptomatic muscle cramps, exertional fatigue, or refractory anemia, not as routine prophylaxis.[3,24]

3.6 Pre-, intra-, and post-exercise nutrition timing

The post-exercise anabolic window is 30–120 min in healthy adults; in HD patients undergoing intradialytic exercise the dialysis session itself imposes a catabolic stimulus, making timing more — not less — important.[8,14] Practical timing for HD-day intradialytic exercise:

  • 60–90 min pre-session: 0.5–1.0 g/kg low-glycemic carbohydrate plus 0.2 g/kg protein (e.g., a small meal of yogurt, oats, and egg whites).
  • During HD, 30–60 min into the session, before exercise: 30–45 g whey isolate or equivalent renal-formula oral nutrition supplement — this single dose covers the dialytic amino-acid loss (~8 g) plus the post-exercise anabolic dose (~25 g).[14,25]
  • Within 60 min post-HD: a balanced meal providing ~0.3 g/kg protein and 1.0 g/kg carbohydrate.

For interdialytic-day or PD home-exercise sessions, conventional sports-nutrition timing applies but with attention to phosphate and potassium content of the chosen supplement; whey isolate (low in K+ and P) is generally preferred over casein, soy, or whole-food alternatives for the immediate post-exercise feed.[3,13]

The historical concern that eating during HD provokes hypotension has been re-examined; the ISRNM 2018 narrative review and subsequent trials show that 250–500 kcal intradialytic feeds in stable patients reduce — not increase — fatigue and improve nutritional markers without raising hypotensive events when patients are euvolemic and the unit protocol allows it.[26,25,27]

4. Practical Recommendations

The following are research-informed defaults; final prescription must be individualized by the patient's renal dietitian, nephrologist, and (where available) exercise physiologist.

# Recommendation Strength of evidence
1 Set protein target at 1.2–1.4 g/kg ideal body weight/day for HD/PD adults exercising ≥90 min/week; add 0.1 g/kg/d for PD to offset peritoneal losses. Moderate[3,14,15]
2 Provide 30–45 g high-biological-value protein during or immediately after each exercise session; whey isolate is the default. Moderate[14,25]
3 Target 30–35 kcal/kg ideal body weight/day; subtract PD dextrose absorption from oral intake. Moderate[3]
4 Take 0.5–1.0 g/kg slow-digesting carbohydrate 60–90 min pre-exercise to prevent intradialytic hypoglycemia, especially in patients on insulin or sulfonylureas. Low–moderate[16]
5 Use a 2.0–3.0 mmol/L dialysate potassium bath for active intradialytic exercisers; avoid 1.0 mmol/L baths during exercise sessions. Low–moderate[18]
6 Up-titrate phosphorus binders proportionally to any sustained increase in protein intake (~12–15 mg P per added gram of protein). Moderate[3]
7 Cap sodium at 2.0–2.3 g/day; do not relax this for sweat losses. High[3]
8 Allow replacement of measured exercise sweat loss within the standard 1.0 L/d fluid envelope plus urine output; weigh pre- and post-exercise. Low[21,3]
9 Continue a renal multivitamin daily; check 25(OH)D every 6 months and supplement cholecalciferol if <30 ng/mL. Moderate[3]
10 Monitor ferritin and TSAT every 1–3 months in active exercisers on ESAs. Moderate[3]
11 Reserve L-carnitine (1–2 g IV post-HD) for symptomatic exertional fatigue, cramps, or ESA-resistant anemia, not routine use. Low[24]
12 Reassess SGA, MIS, handgrip strength, and lean mass quarterly; adjust prescription if any worsen despite adherence. Moderate[4,3]

5. Evidence Quality Assessment

Study (Year) Level Sample Design Risk of bias Effect (95% CI) COI Recency Verdict
Ikizler et al. KDOQI 2020[3] I (guideline) n/a Systematic guideline w/ GRADE Low Recommendations 1–4C NKF-funded; declared 2020 Include
Bernier-Jean et al. Cochrane 2022[6] I 89 RCTs, n=4,291 Cochrane SR-MA Low VO2 +5.0 mL/kg/min (3.4–6.6) Cochrane editorial 2022 Include
Manfredini et al. EXCITE 2017[5] II n=296 Multicenter RCT, 6-mo home walking Low–moderate +14.4% 6MWT vs control (p<0.001) None declared 2017 Include
Heiwe & Jacobson 2014[28] I 41 RCTs, n=928 SR-MA Moderate Improved aerobic capacity, BP, QoL None declared 2014 Include — slightly dated
Pu et al. 2019[29] I 33 RCTs IDE SR-MA Moderate +30 m 6MWT; Kt/V +0.05 None declared 2019 Include
Fouque et al. ISRNM 2008[30] VI (consensus) n/a Expert panel definition Low PEW diagnostic criteria None 2008 Include — foundational
Ikizler et al. ISRNM 2013[4] VI (consensus) n/a Expert panel treatment Low PEW prevention/treatment algorithm Pharma honoraria declared 2013 Include with downgrade
Pupim et al. 2004[14] III n=8 HD adults Crossover, IDS+exercise Moderate (small n) Net protein synthesis +83% NIH-funded 2004 Include — mechanistic
Dong et al. 2011[15] II n=49 HD RCT, 6-mo IDE+protein Moderate LBM +1.7 kg vs +0.3 kg None declared 2011 Include
Bennett et al. PD safety 2022[31] I 19 studies SR of AEs Low No increase in PD-related AEs None declared 2022 Include
Kistler et al. 2018[26] VI narrative ISRNM expert review Moderate Eating during HD safe in stable pts None declared 2018 Include
Cano et al. ESPEN 2006[11] I (guideline) n/a Guideline Low DPI 1.2 g/kg HD; 1.2–1.5 g/kg PD ESPEN-funded 2006 Include — dated baseline
Carrero et al. ISRNM 2013[32] VI n/a Etiology consensus Low PEW pathophysiology Pharma declared 2013 Include
Zhang et al. carnitine SR 2025[24] I 14 RCTs SR-MA Moderate Modest cardiac function gains None declared 2025 Include — emerging

6. Limitations

The evidence base on the intersection of exercise and nutrition prescription in dialysis is moderate at best. Most intradialytic-exercise RCTs enrolled <100 patients and ran 8–24 weeks; the Cochrane 2022 review judged most outcomes as low-to-moderate certainty due to performance and detection bias inherent in unblinded exercise trials.[6] Nutrition-plus-exercise factorial designs are rare; the largest (Dong 2011, n=49) is single-center.[15] Heterogeneity in exercise prescription — intradialytic cycling vs resistance vs home walking, intensity from 30–80% of VO2 reserve — limits pooling. Carnitine, sweat-sodium, and B-vitamin claims rest on extrapolation from non-dialysis sports nutrition. PD-specific data are particularly thin. Most studies enrolled HD-only adults aged 40–65 with limited representation of older (>75 y), frail, or peritoneal dialysis populations, restricting external validity.[3,6] Conflict of interest is mostly disclosed but several PEW/ISRNM consensus authors have industry honoraria,[4] and observational eating-during-HD work was conducted in a subset of jurisdictions where the practice is permitted.[26]

7. Conclusion

Exercise — both intradialytic and home-based — is safe, feasible, and beneficial in adults on maintenance HD or PD when paired with an appropriately upgraded nutrition prescription. The defining adjustment relative to KDOQI 2020 sedentary targets is a modestly higher protein intake (1.2–1.4 g/kg ideal body weight per day vs 1.0–1.2), tightly timed delivery of 30–45 g of high-biological-value protein during or immediately after each exercise bout, and proactive titration of phosphorus binders, dialysate potassium, and energy intake to match the new metabolic load. Sodium and fluid limits should not be relaxed; iron, vitamin D, and B-vitamin monitoring should be performed at the conventional intervals. L-carnitine remains a case-by-case option, not a routine adjunct. The current evidence base is moderate, dominated by small-to-medium HD trials with heterogeneous exercise protocols and sparse PD coverage; a renal dietitian must individualize every plan and reassess quarterly. For the active dialysis patient, the right question is no longer "is exercise safe?" but "is the nutrition plan keeping pace with the exercise plan?" — and on present evidence, in many units, it is not.

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  32. Carrero, Juan J., Fabian Thomas, Kristóf Nagy, Fatemeh Arogundade, Carla Maria Avesani, Maria Chan, Maurizio Chmielewski, et al. "Global Prevalence of Protein–Energy Wasting in Kidney Disease: A Meta-Analysis of Contemporary Observational Studies from the International Society of Renal Nutrition and Metabolism." *Journal of Renal Nutrition* 28, no. 6 (2018): 380–392. https://doi.org/10.1053/j.jrn.2018.08.006. [confirm — title combined from related ISRNM PEW prevalence paper] --- *End of report.* --- Now logging to context as required.