title: A clinical approach to the nutritional care process in protein-energy wasting hemodialysis patients.
abstract: BACKGROUND
  Malnutrition/wasting/cachexia are complex-disease conditions that frequently remain undiagnosed and/or untreated in up to 75% of prevalent hemodialysis (HD) patients. The nutrition care process (NCP) based on assessment, diagnosis, intervention and monitoring of nutritional status is a systematic method that nutrition professionals use to make decisions in clinical practice.
  
  
  OBJECTIVE
  This review examines from a clinical-nutritional practice point of view: a) nutritional status as a mortality causative factor; b) phenotypic characteristics of malnutrition/wasting/cachexia, and c) current trends of NCP with special emphasis on nutritional support and novel nutrient and pharmacologic adjunctive therapies in HD patients.
  
  
  METHODS
  A literature review was conducted using the Pubmed, Science Direct, Scielo, Scopus, and Medline electronic scientific basis. Studies which assessing nutritional status and nutritional support published from 1990 to 2013 in HD patients were included and discussed.
  
  
  RESULTS
  From all the epidemiological data analyzed, NCP was the suggested method for identifying malnutrition/ wasting or cachexia in clinical practice. Nutrition support as an unimodal therapy was not completely able to reverse wasting in HD patients. Novel experimental therapeutic strategies including the use of appetite stimulants, ghrelin agonist, MC4-R antagonists, anabolic steroids, anti-inflammatory drugs, cholecalciferol, and other components are still under clinical evaluation.
  
  
  CONCLUSIONS
  Nutritional status is a strong predictor of morbidity and mortality in HD patients. The terms called malnutrition, wasting and cachexia have different nutritional therapeutics implications. The NCP is a necessary tool for assessing and monitoring nutritional status in the current clinical practice. Novel pharmacological therapies or specific nutrient supplementation interventions studies are required.
authors.affiliation: From Departamento de Nutrición y Bromatología I (Nutrición). Facultad de Farmacia. Universidad Complutense de Madrid.. marruperto@yahoo.com.
authors.forename: Mar
authors.initials: M
authors.lastname: Ruperto
authors.affiliation: From Departamento de Nutrición y Bromatología I (Nutrición). Facultad de Farmacia. Universidad Complutense de Madrid..
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Sánchez-Muniz
authors.affiliation: Servicio de Nefrología. Hospital Universitario La Princesa. Madrid. Spain..
authors.forename: Guillermina
authors.initials: G
authors.lastname: Barril
mesh_terms: D004044:Dietary Proteins / Q000008:administration & dosage / Q000378:metabolism*; D006801:Humans; D044342:Malnutrition / Q000209:etiology / Q000517:prevention & control; D044623:Nutrition Therapy / Q000379:methods*; D006435:Renal Dialysis / Q000009:adverse effects* / Q000379:methods / Q000401:mortality
chemical_list: D004044:Dietary Proteins