The patient with chronic renal failure is commonly malnourished (Ayram...,.a0d M.itim.§0..!994). Restriction of dietary protein ameliorates symptoms of uremia which occur when the glomerular filtration rate has fallen to 40 per cent of normal, and most patients spontaneously modify their protein intake to accommodate this. However, in the absence of expert dietetic input and in the context of an inadequate intake of essential amino acids, this may lead to a negative nitrogen balance in which protein degradation exceeds synthesis and there is marked loss of lean body mass. Energy intake is also important, with calorie malnutrition contributing to a negative nitrogen balance. Physical examination and calculation of the body mass index may suggest protein malnutrition, with hypoalbuminemia and reduced levels of prealbumin and transferrin providing biochemical evidence although these may be misleading in the context of massive proteinuria. Levels of iron, zinc, red cell folate, 1,25-dihydroxyvitamin D, and water-soluble vitamins may be low in chronic renal failure, with pyridoxine deficiency contributing to immune depression and anemia. Supplements should be provided.
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