**3. Protein energy wasting**

The International Society of Renal Nutrition and Metabolism (ISRNM) proposed the term protein-energy wasting (PEW) to characterize multiple metabolic alterations related to uremia, hypercatabolism, cachexia, and malnutrition associated with morbidity and mortality in kidney disease [2, 3, 30].

The major and most common cause of PEW is inadequate protein and energy intake, compounded by anorexia due to uremia, inflammation, dialysis procedure, and acidemia [31]. Insufficient nutrient intake may also result from glucose absorption from peritoneal dialysate and early satiety feeling, poor economic status, depression, and illness that affects gastrointestinal functions [32]. Nutrient loss during RRT, such as peptides, amino acids, vitamins, trace elements, and glucose, further put the patients at risk of PEW [33].

Studies suggest that adequate energy and protein intake, as recommended in **Table 1**, would help prevent PEW. Other strategies include dialysis adequacy, correcting metabolic acidosis, and treating inflammation and co-morbidities such as diabetes [34–36]. When standard preventive measures cannot reduce the loss of energy and protein stores, nutrition supplementation would suffice. A renal dietitian or equivalent can assess the patient for oral and enteral nutrition supplementation and further intradialytic parenteral nutrition [31].
